Saturday, January 29, 2011

Intern Report Case 3.1

Case Presentation by Dr. Jeff Cloyd

A 49-year-old woman is brought into the ED by EMS for a seizure that occurred at home.  The patient was noted to have a history of seizure disorder attributed to a closed-head injury 15 years prior. At triage, the patient began seizing and was subsequently transferred to the resuscitation room.  Her medications include phenytoin and methadone.  Her ethanol intake is approximately 1 – 2 pints of vodka daily.  She has been hospitalized for alcohol withdrawal in the past.

Physical Examination
VS: HR – 108 (triage), 142 (resus.); BP – 158/101 (triage), 204/168 (resus); RR- 28; O2 – 90% RA, 100% non-rebreather; T – 38.7 (R)

Well-developed, disheveled appearing female actively seizing.  Diaphoretic. No evidence of trauma.  Pupils equal and reactive bilaterally (5 mm to 3 mm).  Coarse gurgling breath sounds auscultated bilaterally.  Evidence of chronic IV drug abuse including skin-popping scars and pitting in the inguinal region.



Laboratory evaluation was significant for a glucose of 200, lactate of 9.1, CK 4800, negative troponin, phenytoin level 6.5. 
Negative SDS.
Chest x-ray and head CT negative.
_______________________________________________

Test Your Knowledge
Q1:
The most effective medications used to terminate seizures in the acute setting are benzodiazepines, and Lorazepam is a drug of choice.  Which of the following co-morbidities is most likely to affect the metabolism of Lorazepam?
A)   Chronic essential hypertension
B)   Diabetes mellitus
C)   Hepatitis C
D)   Old age
E)   Acute alcohol intoxication

Q2:
While the medication of choice in the treatment of seizures of any etiology is benzodiazepines (especially alcohol related seizures), the butyrophenones (eg haldol) are particularly effective in the treatment of hallucinations associated with alcohol withdrawal. However, butyrophenones are not devoid of potential side effects including akinesia and dystonia.  Which of the following is the first line medication for treatment of these adverse effects of such a useful drug?
A) Benzatropine
B) Diphenhydramine
C) Clozapine
D) Ondansetron
E) Vitamin E
F) Lorazepam
G) Levodopa
H) Botulinum toxin

Q3:
The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (2003) is a tool that was developed to be used by clinicians to score the severity of a patient’s alcohol withdrawal symptoms.  The impetus behind the production of this scale is to allow physicians to track a patient’s progress through alcohol withdrawal, as well for medical professionals to determine the need for sedative medication based on a numerical value.  Scoring components include nausea/vomiting, tremors, paroxysmal sweating, headache, anxiety, agitation, orientation, and hallucinations.  Which of the following symptom combinations indicate opioid withdrawal or a psychiatric disorder, rather than alcohol withdrawal?
A)   Diarrhea and normal orientation
B)   Fever and visual hallucinations
C)   Normal bowel activity and agitation
D)   Nausea, vomiting and headache

Q4:
One standard alcoholic drink has 14 grams of EtOH – equivalent to a 12 ounce beer, 5 ounce glass of wine, 1.5 ounce shot of alcohol (whiskey, vodka).  The National Institute of Health has developed guidelines defining excessive and potentially harmful amounts of alcohol. For men under the age of 65, ____ drinks per day, or ___ drinks per week is considered potentially harmful.
A) 2, 10
B) 4, 14
C) 6, 12
D) 10, 100

Q5:
Status epilepticus is a medical emergency because constant tonic-clonic seizure activity inhibits the body’s ability to oxygenate and then supply blood to the vital organs (particularly the brain). What constitutes status epilepticus?
A) Continuous, unremitting seizure lasting longer than 30 minutes.
B) Three tonic-clonic generalized seizures occurring within three minutes
C) Any seizure activity that persists where the patient does not fully recover consciousness before re-seizing

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