History of Present Illness:

A patient in their mid-50’s with a history of substance abuse, depression and migraines is brought to the hospital with ALOC.  Medics relate that her roommate found her at home acting bizarre and agitated with some vomit on her shirt.  There was an empty bottle of vodka in the kitchen as well.  There is no evidence of trauma.   The patient is unable to provide a meaningful history, but medics suspect tox/OD.

Vital Signs & Physical Exam:

Vital signs are notable for tachycardia and elevated BP.  She is altered and tremulous with clonus and nystagmus but all findings are symmetric.  It also smells like she has been incontinent of stool.

 

Initial Diagnostic Testing:

  • CBC: normal except for WBC 12
  • Chem-7: normal except for Na 131
  • Other: Beta HCG normal, tox screen normal

What is the most likely diagnosis?

  • A) Stimulant OD
  • B) Serotonin syndrome
  • C) Alcohol withdrawal
  • D) Seizure

SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT

 

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QUIZ ANSWER:

  • A) Stimulant OD – good thought but does not typically cause vomiting, diarrhea, nystagmus or clonus
  • B) Serotonin syndrome – CORRECT – can be caused by triptans.  She was on Maxalt for migraines
  • C) Alcohol withdrawal – good thought but does not typically cause diarrhea, nystagmus or clonus
  • D) Seizure – good thought but she should be normalizing by now if that were the case

1-Minute Consult on this topic: Click HERE and scroll to page 316.

 

CASE CONCLUSION: She was treated with benzos and admitted to ICU on a 5150 hold.  She did not require cyproheptadine.  She got worse for about 12 hours then gradually improved over 48 hours and was discharged to a psychiatric facility. She admitted to an intentional overdose of Maxalt and Lamictal.