Problem 6
These questions and answers are designed to give you an opportunity to use some of the pharmacological knowledge you have acquired during the semester, by exploiting observation and data collected during five emergency room admissions in order to develop a differential diagnosis of each patient’s problem. ( Non-drug-related diagnoses will not be considered here, but they will be among your first choices when actually working in a hopsital emergency room. ) You should first review each case history, and then prepare yourself to answer the following questions about each case before attempting to answer the specific questions following it, keeping in mind that the object is to treat a sick patient, not a drug:
- What is the epidemiology of the agent that was probably responsible for his sympton? Are recurrences likely, or possible?
Before you begin to study these cases, you may wish to review normal values for the various vital signs, including pulse, blood pressure, respiratory rate, and pupil diameter. HEIGHT=”28″>
| Vital Sign | Normal Values |
HEIGHT=”28″>
| Pulse | 60-80 at rest, awake; 50-70 asleep |
| Blood pressure | 100-140/60-90 mm Hg |
| Respiratory rate | 14-18 / min |
| Temperature |
|
| Pupil diameter | 3-4 mm in average lighted room |
| Urine output | 0.4 – 1.0 ml/min |
CASE 1
The patient is a slightly overweight 50 year-old man who is brought to the emergency room by ambulance after his wife found him unconscious in their garage. He does not respond to verbal or painful stimuli, and his deep tendon reflexes are diminished. Neither alcohol nor fruity odors are detectable in his breath. His vital signs are: Pulse = 90 bpm; BP = 140/90 mmHg; Respirations = 32/min; Temp. (rectal) = 97.4F. His pupil diameter is 4mm, and his pupils respond sluggishly to light. Routine blood cell counts are within normal limits. The patient is moderately cyanotic, and ausculation reveals fluid in his lungs. His bladder is catheterized at admission; two hour later his total urine output is measured at 20 ml. At that time, his BP is 120/60 mmHg, his pulse is 52bpm, and his respirations are 8-10/min. I. This patient’s signs and symptoms might plausibly have been produced by:
- a. An overdose of heroin.
- b. An overdose of diazepam.
- c. An overdose of a barbiturate.
- d. An unusual sensitivity to a conventional euphorigenic dose of cocaine.
- e. An all-night drinking binge.
II. Appropriate therapy for this patient should include: HEIGHT=”106″>
| 1) Gastric lavage and/or other techniques for removing the drug from the gastrointestinal tract. |
| 2) Oxygen. |
| 3) A diuretic. |
| 4) Dopamine or dobutamine. |
| 5) Naloxone. |
- a. 1. above.
- b. 2. above.
- c. 1, 2, and 3 above.
- d. 1, 2, 3, and 4 above.
- e. All five of the above treatments.
CASE 2.
The patient, a well-developed, well-nourished, 33 year-old man, is brought to the Emergency Room by the police officers who found him staggering along a street near the hospital. He tells you this is the worst headache he’s had since he began having them every week or two about a year ago. Although he seems oriented in respect of time and place, emergency room personnel agree that his affect is inappropriate, partly because he refuses to answer further questions about his medical history, including illicit drug use. Neurological exam reveals left ataxic hemiparesis, although deep tendon and pain reflexes are normal. No recognizable odors are detectable in his breath. His vital signs are: Pulse = 104 bpm; BP = 170/116; Respirations = 22/min; Temp. = 99.0F. Both pupils measure 6mm in diameter and respond promptly to light. He is able to provide a urine sample with ease. The hospital computer tells you that the patient was admitted for a myocardial infarction eight months ago, and that his record will be delivered to you shortly. III. This patient’s signs and symptoms might plausibly have been produced by:
- a. An overdose of heroin.
- b. The ingestion of berries that contain substantial amounts of cholinergic antagonists.
- c. An overdose of an amhetamine.
- d. An overdose of cocaine. .
- e. None of the above seems likely.
IV. Appropriate therapy for this patient should include:
CASE 3.
The patient is a rather overweight 19 year-old male aspring college athelete who has been sent by ambulance by the college health service because he had complained of severe headache, and because his BP is 230/142. Upon admission to the Emergency Room, he is highly agitated. His BP is unchanged and his pulse is 48. Respirations = 20/min; Tmep. = 98.2F; Pupil diameter = 3mm. The patient denies any history of illicit drug use, and you find no reason not to believe him. His past medical history is not remarkable, and he appears in all respects save for his headache and vital signs. Urinalysis and blood counts are normal. While you are completing the essentially unremarkable neurological examination of this patient, he slumps forward and falls off the examining table. V. This patient’s signs and symptoms might plausibly have been produced by:
- a. An attempt to commit suicide with chlorpromazine.
- b. Accidental ingestion of a decongestant containing pseudoephedrine.
- c. A euphorigenic dose of phencyclidine.
- d. An overdose of an appetite suppressant containing phenylpropanolamine.
VI. Appropriate therapy for this patient should include:
- a. A vasodilator.
- b. A vasopressor.
- c. An a – antagonist.
- d. Diazepam.
- e. Ammmonium chloride.
- f. Two of the above.
CASE 4
A 55 year-old professor of biochemistry is brought to the Emergency Room by ambulance. His wife had found him unconscious in their large apple and peach orchard two hours previously, and summoned help when she was unable to rouse him. She tells you that her husband has been complaining of stomach cramps, severe nausea that “made him feel like he was always going to throw up”, and diarrhea, all for about ten days, and that a couple of days ago he mentioned that things looked “fuzzy”, that maybe he should see an ophthalmologist. Otherwise, he has been in fairly good health for many years, although a cardiologist has been following his mild hypertension. On physical examination the patient is sweating profusely (although the examining room is well air conditioned), copious saliva is drooling from his mouth, and his skin is cyanotic. BP = 148/92; Pulse = 72 bpm; Respirations = 36/min; Temp. (rectal) = 97.8 F. Pupil diameter = 1.5 min; both pupils are unresponsive to light, but his fundi are normal. Ausculation reveals fluid in the lungs. He is in deep coma, perhaps worsening; he does not respond to painful stimuli. At the time you first see him his muscles are twitching, but by the end of your examination, his limbs are completely flaccid, and deep tendon reflexes are absent. His bladder empties spontaneously (of 100 ml urine) before it can be catheterized. Conventional blood chemistries and blood cell counts are normal. VII. This patient’s signs and symptoms might plausibly have been produced by:
- a. Ingestion of Solanum dulcamara berries, as in Item IIIb above.
- b. Inhalation of parathion spray.
- c. Inhalation of nicotine from the tobacco dust in a neighbor’s barn.
- d. A suicidal dose of acetaminophen.
- e. None of the above seems remotely possible.
VIII. Appropriate therapy for this patient would include:
- a. Atropine.
- b. A vasopressor.
- c. An a-antagonist.
- d. An agent that can change urinary pH.
- e. An agent that dephosphorylates cholinesterase.
- f. Two of the above.
CASE 5
A 36 year-old man who has been widowed recently is found unconscious in his apartment by a neighbor who calls for an EMT team. Because he is in a deep coma, the EMTs elect simply to start IV fluids (without any medication) and bring him to the Emergency Room. BP = 120/65; Pulse = 285/min (as recorded on the EKG); Respirations = 18/min; Temp. = 99.5 F; Pupil diameter is 5mm, with only slight response to light. Otherwise, the physical examination is generally unremarkable, although the bladder is palpable a handsbreadth above the symphysis pubis. Babinski signs are present, and deep tendon reflexes are absent. Conventional blood chemistries and cell counts are normal. The friend who found the patient tells you he had appeared highly agitated earlier in the day, and assures you that the patient has no history of drug abuse. IX. This patient’s signs and symptoms might plausibly have been produced by:
- a. An antianxiety drug, probably diazepam.
- b. An antidepressant, probably amitryptiline.
- c. A stimulant such as amphetamine.
- d. An anticholinergic agent, such as atropine.
- e. An antiarrhythmic drug such as quinidine
X. Appropriate therapy for this patient might include many different agents, such as:
