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As the medical intern on call, you are summoned at 1:00 am to the locked unit of the psychiatric ward to evaluate a 32-year-old woman admitted involuntarily after a suicide attempt. She was treated in the emergency room (ER) 1 hour ago for a diazepam overdose and is currently on a 72-hour hold. At the bedside you observe that the patient is intensely agitated and writhing in apparent pain. She is crying and sweating profusely. Vital signs are temperature: 37.8°C (100°F), blood pressure (BP): 160/100, heart rate (HR): 105 beats/min, and respiratory rate (RR): 15 breaths/min. Skin is cool and clammy with prominent piloerection. Pupils are 8 mm and equal. The remainder of the physical exam is normal. Which detail of patient history best correlates with the patient's current condition?

A. Patient drinks 6 to 10 vodka cocktails per day
B. Patient has a seizure disorder
C. Patient has a somatoform disorder
D. Patient overdosed on imipramine
E. Patient received naloxone in the ER

!!!!! plz read it through carefully, ans in qbank raised my eyebrow twice, terse ... picky q.
 

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A. Patient drinks 6 to 10 vodka cocktails per day

Flumazenil does not antagonize all of the central nervous system effects of drugs affecting GABA-ergic neurons by means other than the benzodiazepine receptor (including ethanol, barbiturates, or general anesthetics) and does not reverse the effects of opioids.
 

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agree, with the other guys. first signs of alcohol withdrawal.
but since u raised ur eyebrow twice :)):)) may be that is not the ans :indifferent:
 

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Her s/s are typical of opioid withdrawal (piloerection, dilated Pupils). Maybe she was on Methadone?

Fully developed symptoms of opiate withdrawal result from overactivity of the sympathetic
nervous system
and include lacrimation, rhinorrhea, dilated pupils, piloerection, diaphoresis,
yawning, hypertension, tachycardia, and fever.
 

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i think its D..
cos of extensive anticholinergic symptoms.. and TCAs have anticholinergic action.

:eek::confused:
:confused::):sorry:
The symptoms of an anticholinergic toxidrome include blurred vision, coma, decreased bowel sounds, delirium, dry skin, fever, flushing, hallucinations, ileus, memory loss, mydriasis (dilated pupils), myoclonus, psychosis, seizures, and urinary retention. Complications include hypertension, hyperthermia, and tachycardia. Substances that may cause this toxidrome include the four "anti"s of antihistamines, antipsychotics, antidepressants, and antiparkinsonian drugs[3] as well as atropine, benztropine, datura, and scopolamine.
 

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Discussion Starter #9
As the medical intern on call, you are summoned at 1:00 am to the locked unit of the psychiatric ward to evaluate a 32-year-old woman admitted involuntarily after a suicide attempt. She was treated in the emergency room (ER) 1 hour ago for a diazepam overdose and is currently on a 72-hour hold. At the bedside you observe that the patient is intensely agitated and writhing in apparent pain. She is crying and sweating profusely. Vital signs are temperature: 37.8°C (100°F), blood pressure (BP): 160/100, heart rate (HR): 105 beats/min, and respiratory rate (RR): 15 breaths/min. Skin is cool and clammy with prominent piloerection. Pupils are 8 mm and equal. The remainder of the physical exam is normal. Which detail of patient history best correlates with the patient's current condition?

A. Patient drinks 6 to 10 vodka cocktails per day
B. Patient has a seizure disorder
C. Patient has a somatoform disorder
D. Patient overdosed on imipramine
E. Patient received naloxone in the ER

!!!!! plz read it through carefully, ans in qbank raised my eyebrow twice, terse ... picky q.
ans is E.

Option E (Patient received naloxone in the ER) is correct. The opiate withdrawal syndrome is unique in all of addiction medicine. The piloerection; cool, clammy skin; and mydriasis results from an intense hyperadrenergic state. Naloxone blocks opiate receptors and can induce a withdrawal state in opiate addicts.

Option A (Patient drinks 6 to 10 vodka cocktails per day) is incorrect. Acute alcohol withdrawal does produce profuse sweating and cardiovascular lability, but does not cause the classic hyperadrenergic symptoms of opiate withdrawal including mydriasis and piloerection.

Option B (Patient has a seizure disorder) is incorrect. Neither seizure activity nor side effects of seizure medications would manifest as a hyperadrenergic state. The patient shows classic symptoms of opiate withdrawal including mydriasis; cool, clammy skin; and piloerection.

Option C (Patient has a somatoform disorder) is incorrect. Psychiatric disorders should not directly result in a physiological hyperadrenergic state. The patient shows classic hyperadrenergic symptoms of opiate withdrawal including mydriasis; cool, clammy skin; and piloerection.

Option D (Patient overdosed on imipramine) is incorrect. Tricyclic antidepressant toxicity produces anticholinergic symptoms including mydriasis and flushed skin. This patient shows classic hyperadrenergic symptoms of opiate withdrawal including mydriasis; cool, clammy skin; and piloerection.
explanation is not good. does it make sense to everyone? if i get this q again, i would do wrong again:D:D:D:)):)):))
 

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ans is E.
explanation is not good. does it make sense to everyone? if i get this q again, i would do wrong again:D:D:D:)):)):))
Makes sense to me.

Naloxone is a drug used to counter the effects of opiate overdose.
If you give it to someone who is a CHRONIC opiate user then it will precipitate acute withdrawal symptoms as seen in this patient.
Naloxone is routinely given in ER to patients suspected of drug overdose.
I think the point of this question was to always suspect multiple drug use in a patient and know the contraindications to the use of various antidote(s).
 
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