Bryan s judge md iusom medical toxicology fellowship acmt cpc competition september 5 2003
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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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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

Case Presentation

  • 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

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


Social history

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


Case presentation1

Case Presentation

  • Patient remained dyspneic upon arrival to the tertiary referral hospital

  • Patient denied use of cocaine, heroin, or methamphetamine for several days


Case presentation2

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


Case presentation3

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

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


Pertinent physical exam findings1

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


Complete blood count

Complete Blood Count

15.8

15.9

240

45.0

60% Neutrophils

26% Lymphocytes

6% Monocytes


Chemistry panel

Chemistry Panel

138

12

105

141

4.6

23

0.7

Anion gap = 10


Other studies

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


Other studies1

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


Other studies2

Other Studies

  • Urine Drug Screen:

    • Amphetamines – Negative

    • Cocaine – Negative

    • THC – Positive

    • Benzodiazepines – Negative

    • Barbiturates – Negative

    • Tricyclic Antidepressants – Negative

    • Opiates – Negative


Making the diagnosis

Making The Diagnosis

  • Further history provided by the patient helped to elicit the etiology behind his clinical condition


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