doc_clotaire
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A 40-year-old woman is brought to the emergency department by her
daughter who states that she found her mother at home several hours
ago, confused, lethargic, and unable to get up from her chair or
speak. Her mother has a seizure disorder for which takes an
antiseizure medication. She also has a history of alcohol abuse in the
remote past. For the past several weeks, her mother has been
complaining of difficulty sleeping and anxiety. The patient is
stuporous and unresponsive to verbal stimuli. Her blood pressure is
100/60 mm Hg, heart rate is 50/min, and respiratory rate is 9/min. The
pupils are pinpoint, and there is horizontal nystagmus. Asterixis is
present.
Laboratory examinations reveal: white cell count 9,800/mm3, sodium 150
mEq/L, BUN 18 mg/dL, creatinine 0.9 mg/dL, glucose 50 mg/dL, calcium 5
mg/dL, ammonia 100 μg/dL, albumin 3.0 g/dL, AST 100 U/L, ALT 80
U/L. The urinalysis and lumbar puncture are normal. A CT scan of the
brain shows cerebral edema. Arterial blood gas shows a pH of 7.20, a
pCO2 of 46 mm Hg, and a pO2 of 79 mm Hg. Osmolar gap is zero. The
toxicology screen is negative for benzodiazepines and opioids. What is
the most likely substance that this patient overdosed on?
(A) Phenytoin
(B) Carbamazepine
(C) Valproic acid
(D) Ethanol
(E) Valium
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| sprint123
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I could definitely rule out Carbamazepine due to its anti-cholinergic action..
Pin-point pupils doesn't go well with other drugs and valium -I think is a BDZ nd hence is it ethanol???
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| r_albayunen
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hmmm .. i though ethanol also due to hypoglycemia, tremors, and as you can see a clue AST is greater than the ALT which always points to either drug induced or alcoholic hep .. and this are all drugs! oh well .. suggestions?!?!!
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| muna
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valproic acid
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| snake0613
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d?
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| mdwannabe
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A: Phenytoin: Slow pulse, confusion, nystagmus, rest of smx are from previous ETOH abuse, Urine tox is clear. Carbamazepine can cause similar effects, but no cardiac or BP effects... Hence.. Phenytoin.
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| doc_clotaire
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C) Valproic acid
Explanation:
This patient most likely is intoxicated with valproic acid. This drug
is widely used in the management of seizure and mood disorders.
Valproic-acid intoxication produces a unique syndrome consisting of
hypernatremia, metabolic acidosis, hypocalcemia, elevated serum
ammonia, and mild liver aminotransferase elevation. Hypoglycemia may
occur as a result of hepatic metabolic dysfunction. Coma with small
pupils may be seen, and this can mimic opioid poisoning.
Encephalopathy and cerebral edema can occur.
Phenytoin and carbamazepine are also commonly used antiseizure
medications. Phenytoin intoxication can occur with only slightly
increased doses. The overdose syndrome is usually mild. The most
common manifestations are ataxia, nystagmus, and drowsiness. Hepatic
encephalopathy would be unusual. Choreoathetoid movements are
occasionally seen. Carbamazepine is a first-line agent for temporal
lobe epilepsy, as well as trigeminal neuralgia. Intoxication causes
drowsiness, stupor, coma, or seizures. However, dilated pupils and
tachycardia are more common.
Signs of ethanol intoxication are similar to the signs of
anticonvulsant medication. In addition, it causes a high osmolar gap.
Valium is an unlikely cause of intoxication because this patient's
blood benzodiazepine levels are negative.
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