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

The Shit That Killed A Rock Star. 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

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

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  1. The Shit That Killed A Rock Star Bryan S Judge, MD IUSOM Medical Toxicology Fellowship ACMT CPC Competition September 5, 2003

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

  3. 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

  4. 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

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

  6. 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

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

  8. Pertinent Physical Exam Findings • Vitals: T- 98.3°F RR- 30/min P- 105/min BP- 112/72 mmHg O2 Sat- 82% on room air O2 Sat- 91% on 100% NRB • General: Well nourished and in mild respiratory distress

  9. 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

  10. Complete Blood Count 15.8 15.9 240 45.0 60% Neutrophils 26% Lymphocytes 6% Monocytes

  11. Chemistry Panel 138 12 105 141 4.6 23 0.7 Anion gap = 10

  12. Other Studies • Calcium: 8.6 mg/dL • Arterial Blood Gas on Room Air: • pH: 7.40 • pCO2: 34 mmHg • pO2: 46 mmHg • HCO3-: 23 mEq/L

  13. 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

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

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

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