“night on the town”
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A 22-year-old female is brought into the ED via ambulance because of a suicide attempt. Soon after a “night on the town” she called her boyfriend after a fight and said she took a handful of sleeping pills.
On exam, she is lethargic, but groins and moves all her extremities to painful stimuli. Her blood pressure is 110/70, heart rate is 80 and oxygen saturation 99 percent. Her pupils are normal size and reactive to light. Her deep tendon reflexes are normally bilaterally. In the field she was given an IV bolus of dextrose with an amp or Narcan without response. Her boyfriend, with whom she had an argument brings in a bottle of sleeping medication that reads lorazepam.
What is your diagnosis and differentials? Use VINDICATE
What would be important to know about this patient? Include testing
What is your treatment plan? Explain.
Sample Solution
Diagnosis: Acute Intoxication with Lorazepam
Differentials:
1) V: Volume Depletion – The patient is not significantly dehydrated, and there is no history of vomiting or diarrhea.
2) I: Infectious Disease – There is no evidence that the patient has an infectious disease, or any associated fever, chills, or other symptoms.
3) N: Neuropathy/Neurologic Injury – The exam confirms that the patient does not have a neuropathy or neurologic injury as her pupils are normal size and reactive to light, her deep tendon reflexes are bilaterally present and she groans and moves all extremities in response to painful stimuli.
4) D: Drug/Toxin Exposure – The bottle of medication brought to the ED by her boyfriend was lorazepam which supports a diagnosis of acute intoxication with this drug. Additionally, her lack of response during the field bolus suggests a toxin related etiology for her condition.
5) I: Immunologic Injury- No immunologic injury was reported in this case though it should be further investigated if other symptoms develop over time.
6) C: Cardiovascular Dysfunction – Her blood pressure and heart rate are within normal range thus ruling out cardiovascular dysfunction as a contributor in this case.
7) Ate: Metabolic Disturbance- As mentioned earlier there were no signs of metabolic disturbance on physical exam (i.e., dehydration). However given the fact that she ingested medications it would be prudent to measure electrolytes when possible as they can be affected by certain drugs (i.e., diuretics).
8 ) T : Trauma – There is no evidence suggesting trauma or mechanical injury in this case so it should not be included as part of differentials for now.
Differentials:
1) V: Volume Depletion – The patient is not significantly dehydrated, and there is no history of vomiting or diarrhea.
2) I: Infectious Disease – There is no evidence that the patient has an infectious disease, or any associated fever, chills, or other symptoms.
3) N: Neuropathy/Neurologic Injury – The exam confirms that the patient does not have a neuropathy or neurologic injury as her pupils are normal size and reactive to light, her deep tendon reflexes are bilaterally present and she groans and moves all extremities in response to painful stimuli.
4) D: Drug/Toxin Exposure – The bottle of medication brought to the ED by her boyfriend was lorazepam which supports a diagnosis of acute intoxication with this drug. Additionally, her lack of response during the field bolus suggests a toxin related etiology for her condition.
5) I: Immunologic Injury- No immunologic injury was reported in this case though it should be further investigated if other symptoms develop over time.
6) C: Cardiovascular Dysfunction – Her blood pressure and heart rate are within normal range thus ruling out cardiovascular dysfunction as a contributor in this case.
7) Ate: Metabolic Disturbance- As mentioned earlier there were no signs of metabolic disturbance on physical exam (i.e., dehydration). However given the fact that she ingested medications it would be prudent to measure electrolytes when possible as they can be affected by certain drugs (i.e., diuretics).
8 ) T : Trauma – There is no evidence suggesting trauma or mechanical injury in this case so it should not be included as part of differentials for now.