Ivonne
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A 40 yo F is brought by her daughter to the ER saying that She found her mother at home several hours before, confused, lethargic and unable to get up from the chair or speak. Her mother has a seizure disorder for which She takes medication. She also has a h/o alcohol abuse in the remote past. For the past several weeks her mother is complaining of anxiety and difficulty sleeping.The patient is stuporous and unresponsive to verbal stimuli. Her BP is 100/60, HR: 50 and RR is 9/min. The pupils are pinpoint and there is horizontal nistagmus. Asterixis is present.
LABS: WBC: 8200, Sodium: 150, BUN:18, Creatinine: 0.9, Glucose: 50, Calcium: 7, ammonia:100, Albumin: 3, TGO: 100, TGP:80. UA is normal and Lumbar pucture is normal. A CT scan of the brain shows cerebral edema. ABG: pH: 7.2, pCO2:46, pO2:79 and osmolar gap is zero. The toxicology screen is negative for opioids and benzodiazepines. What is the most likely substance that this patient is overdosed on?
a. Phenytoin
b. Carbamazepine
c. Valproic acid
d. Ethanol
e. Valium
Explain your answer pz
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| hero
Forum Elite
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my guess is C
just based on that it is acid and pt is acidotic 
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| new_n_lost
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c. Valproic acid
In the first look the questions stimulates teh recall of all the Respiratory Depression and Diplopia causing drugs. Phenytoin and Carbamazepine are the ones that stick to mind. I would have most likely chosen Phenytoin if i hadnt paid attention to the " Cerebral Edema" this is most known complication of Valporate poisioning even the levels are subsiding in the body.
I also again didnt pay attention to what i was writing earlier. Confused it all.
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| gingko
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wouldnt it be ethanol because of the hypoventilation and the hypoglycemia. Doesnt alcohol cause respi. depression(which i guess is an indication for dialysis)
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| tamerbashir
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may be E ?
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| cool doctor
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I think E
benzos produce resp depression in alcoholic pts.
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| Ivonne
Forum Guru
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The correct answer is valproic acid that cause a unique syndrome:
- HYPERNATREMIA
- METABOLIC ACIDOSIS
- HYPOCALCEMIA
- ELEVATED SERUM AMMONIA
- ELEVATED TRANSAMINASES AND HYPOGLYCEMIA DUE TO HEPATIC METABOLIC DYSFUNCTION
- COMA WITH SMALL PUPILS MAY BE SEEN
- ENCEPHALOPATHY AND CEREBRAL EDEMA CAN OCCUR
Ethanol intoxication would cause a high osmolar gap
Valium: nooooo The patient was already screened for benzodizepines and it was negative.
Thanks all, now i will remember this 
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| hero
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it doesn't looks like CK question.
more advanced like IM boards or something
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| Ivonne
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They are Fischer questions
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