MarkSeve808 Posted September 2, 2010 Report Share Posted September 2, 2010 An HIV positive male with a history of IV drug abuse and schizophrenia is brought to the emergency department in a confused, incoherent and agitated state. Vitals are pulse 118, BP 160/90, respiratory rate 15, and temperature is 37.5 celcius orally. His skin is hot and flushed and you noticed he has dilated pupils. The physical examination is otherwise unremarkable. Medical records indicate that his regular medications include chlorpromazine, cogentin, and acyclovir. The most likely diagnosis is which of the following conditions: A. HIV encephalopathy B. Anticholinergic intoxication C. Neuroleptic malignant syndrome D. Septicemia E. Heroin withdrawal ??????? Link to comment Share on other sites More sharing options...
leviathan Posted September 2, 2010 Report Share Posted September 2, 2010 It could actually be anticholinergic intoxication (he's on CPZ AND cogentin?), OR NMS based on the presentation. I would just go with the former ( since he's on two separate drugs that have anticholinergic activities, but don't exactly know how you'd rule out NMS. Link to comment Share on other sites More sharing options...
rogerroger Posted September 4, 2010 Report Share Posted September 4, 2010 Dilated pupils - that clinches it for anticholinergic OD no? Admin. a cholinesterase inhibitor and give activated charcoal? Link to comment Share on other sites More sharing options...
WaveSense Posted September 5, 2010 Report Share Posted September 5, 2010 Rogerroger, did you learn what you needed to solve this problem in second year at uoft? Link to comment Share on other sites More sharing options...
bustylegs Posted September 5, 2010 Report Share Posted September 5, 2010 Dilated pupils - that clinches it for anticholinergic OD no? Admin. a cholinesterase inhibitor and give activated charcoal? I don't think it would be unreasonable to let the pt be for the moment. Supportive care for now. Maybe further workup for cause of delerium. It'll be hard to discern if his altered mental state is strictly secondary to medication, or secondary to HIV, CMV, HSV etc. Link to comment Share on other sites More sharing options...
Fred Posted September 6, 2010 Report Share Posted September 6, 2010 An HIV positive male with a history of IV drug abuse and schizophrenia is brought to the emergency department ina confused, incoherent and agitated state. Vitals are pulse 118, BP 160/90, respiratory rate 15, and temperature is 37.5 celcius orally. His skin is hot and flushed and you noticed he has dilated pupils. The physical examination is otherwise unremarkable. Medical records indicate that his regular medications include chlorpromazine, cogentin, and acyclovir. The most likely diagnosis is which of the following conditions: A. HIV encephalopathy B. Anticholinergic intoxication C. Neuroleptic malignant syndrome D. Septicemia E. Heroin withdrawal ??????? A. nope...vitals should be within normal range B. pretty much textbook case... C. fever is indeed missing D. you got two criteria for SIRS and he could be in shock (shock alters your sensorium...) but that's not it... E. B is more likely... He probably took too much cogentin...some people get a mild euphoric effect... Dilated pupils - that clinches it for anticholinergic OD no? Admin. a cholinesterase inhibitor and give activated charcoal? I'd give a AchE inhibitor... I'd also give Sodium bicarb...which protects the heart in case of a long QTc (anti-cholinergic effect) I wouldn't give activated charcoal, I'm not fond of giving stuff that's gonna make people who don't protect their airways throw up....If he's intubated and he gets it through a NG tube I'd be fine with it.. Link to comment Share on other sites More sharing options...
MarkSeve808 Posted September 20, 2010 Author Report Share Posted September 20, 2010 Hey guys here's the full answer: Explanation The correct answer is choice B. This patient exhibits evidence of the anticholinergic toxidrome. This syndrome is best described as "hot as a hare, dry as a bone, and mad as a hatter." It also produced pupil dilation, urinary retention (an important differentiating factor compared with sympathomimetic syndromes), and seizures. He is currently taking two medications (chlorpromazine and cogentin) that produce anticholinergic symptoms. HIV encephalopathy (choice A) is a subacute process progressing over several weeks to months and is usually associated with lethargy and fatigue. Neuroleptic malignant syndrome (choice C) is a complication of anti-psychotic drugs. Symptoms include delirium and elevated temperature. Septicemia (choice D) is a possible cause of altered mental status, especially in an HIV patient. Sepsis is normally associated with a fever and hypotension. Heroin withdrawal (choice E) causes severe muscle cramps, diarrhea, nausea, fever, autonomic instability. Suggested References Hack, Jason B and Hoffman, Robert S. General management of poisoned patients. Chapter 156 in Emergency Medicine: A Comprehensive Study Guide, Tintinalli, Judith (editor). 6th Edition. New York : McGraw Hill, 2004. Link to comment Share on other sites More sharing options...
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