Bryan S Judge, MD IUSOM Medical Toxicology Fellowship ACMT CPC Competition September 5, 2003 Bryan S Judge, MD IUSOM Medical Toxicology Fellowship ACMT CPC Competition September 5, 2003

Case Presentation 25 year-old male Chief complaint: Dyspnea Diagnosed with Pneumocystis carinii pneumonia at another ED Patient transferred to a tertiary referral hospital 25 year-old male Chief complaint: Dyspnea Diagnosed with Pneumocystis carinii pneumonia at another ED Patient transferred to a tertiary referral hospital

Past Medical History Illicit drug abuse with several prior admissions to drug rehabilitation centers Negative HIV antibody test within the last year Denies regular use of any prescription or OTC medications Has no known drug allergies Illicit drug abuse with several prior admissions to drug rehabilitation centers Negative HIV antibody test within the last year Denies regular use of any prescription or OTC medications Has no known drug allergies

Social History History of intravenous cocaine, heroin and methamphetamine abuse Unemployed, lives with girlfriend Smokes 1 pack of cigarettes/day Denies use of ethanol Occasional marijuana use History of intravenous cocaine, heroin and methamphetamine abuse Unemployed, lives with girlfriend Smokes 1 pack of cigarettes/day Denies use of ethanol Occasional marijuana use

Case Presentation Patient remained dyspneic upon arrival to the tertiary referral hospital Patient denied use of cocaine, heroin, or methamphetamine for several days Patient remained dyspneic upon arrival to the tertiary referral hospital Patient denied use of cocaine, heroin, or methamphetamine for several days

Case Presentation He admitted to taking 2 carisoprodol tablets within the last 24 hours Patient denied any cough, fever, chills, chest pain, recent weight loss, or sharing of needles He admitted to taking 2 carisoprodol tablets within the last 24 hours Patient denied any cough, fever, chills, chest pain, recent weight loss, or sharing of needles

Case Presentation “Yeah, the shit that killed [rock star]. I knew it had to be a good trip if it killed [rock star]!”

Pertinent Physical Exam Findings Vitals: T- 98.3°F RR- 30/min P- 105/min BP- 112/72 mmHg O 2 Sat- 82% on room air O 2 Sat- 91% on 100% NRB General: Well nourished and in mild respiratory distress Vitals: T- 98.3°F RR- 30/min P- 105/min BP- 112/72 mmHg O 2 Sat- 82% on room air O 2 Sat- 91% on 100% NRB General: Well nourished and in mild respiratory distress

Pertinent Physical Exam Findings Heart: Tachycardic without murmur or rub Lungs: Diffuse rales bilaterally Extremities: Track marks in the left antecubital fossa and multiple tattoos on chest and arms Remainder of exam is unremarkable Heart: Tachycardic without murmur or rub Lungs: Diffuse rales bilaterally Extremities: Track marks in the left antecubital fossa and multiple tattoos on chest and arms Remainder of exam is unremarkable

Complete Blood Count % Neutrophils 26% Lymphocytes 6% Monocytes 60% Neutrophils 26% Lymphocytes 6% Monocytes

Chemistry Panel Anion gap = 10

Other Studies Calcium: 8.6 mg/dL Arterial Blood Gas on Room Air: –pH: 7.40 –pCO 2 : 34 mmHg –pO 2 : 46 mmHg –HCO 3 - : 23 mEq/L Calcium: 8.6 mg/dL Arterial Blood Gas on Room Air: –pH: 7.40 –pCO 2 : 34 mmHg –pO 2 : 46 mmHg –HCO 3 - : 23 mEq/L

Other Studies ECG: –Sinus tachycardia –QRS – 88 msec –QTc – 390 msec –No ectopy and no ischemic changes Salicylate, APAP and Ethanol Levels: –All are nondetectable ECG: –Sinus tachycardia –QRS – 88 msec –QTc – 390 msec –No ectopy and no ischemic changes Salicylate, APAP and Ethanol Levels: –All are nondetectable

Other Studies Urine Drug Screen: –Amphetamines – Negative –Cocaine – Negative –THC – Positive –Benzodiazepines – Negative –Barbiturates – Negative –Tricyclic Antidepressants – Negative –Opiates – Negative Urine Drug Screen: –Amphetamines – Negative –Cocaine – Negative –THC – Positive –Benzodiazepines – Negative –Barbiturates – Negative –Tricyclic Antidepressants – Negative –Opiates – Negative

Making The Diagnosis Further history provided by the patient helped to elicit the etiology behind his clinical condition