Mehl. Intoxication bullet cases + NBME 10 10Q, 86Q.

Question 1

M. 16M + belligerent (karingas) + nystagmus; Tx?

Answer 1

lorazepam (benzo for PCP toxicity).

Question 2

M. 16M + mutism + constricted pupils; Dx?

Answer 2

PCP intoxication;

student says “Wtf? I thought there was belligerence / bellicosity?” This is one of the presentations on the NBME; if you don’t believe me, Google “Mutism constricted pupils PCP.”

Question 3

M. 16M + found on floor in school bathroom + sluggish + vitals and pupils normal; Dx?

Answer 3

butane toxicity (inhalant toxicity); student had this on actual USMLE.

Question 4

M. 14M + ataxia + cognitive decline; Dx?

Answer 4

glue toxicity, not EtOH.

Question 5

M. 14M + dilated pupils + tachycardia; Dx?

Answer 5

Cocaine

Question 6

M. 14M + dilated pupils + tachycardia; Tx?

Answer 6

benzo (cocaine).

Question 7

M. 14M + dilated pupils + visual hallucinations + staying up all night; Dx?

Answer 7

amphetamine

Question 8

M. 14M + dilated pupils + visual hallucinations + staying up all night; Tx?

Answer 8

benzo
(amphetamine).

Question 9

M. 3M + microcytic anemia + one-month Hx of poor coordination, anorexia, irritability, and apathy; what
could have prevented this?

Answer 9

“elimination of lead from the child’s home”; Tx = succimer for
kids (if lead levels >44 ug/dL); lead can cause microcytic anemia.

Question 10

M. 3M + microcytic anemia + one-month Hx of poor coordination, anorexia, irritability, and apathy; Tx?

Answer 10

succimer for
kids (if lead levels >44 ug/dL); lead can cause microcytic anemia.

intoxication of lead

Question 11

M. 2M + blisters on tongue/mouth + next best step?

Answer 11

fiberoptic endoscopy

Question 12

M. 2M + blisters on tongue/mouth. Dx?

Answer 12

exposure to drain cleaner.

Question 13

M. 16F + found by mom 20 minutes ago + consumed bottle of aspirin in suicide attempt + lethargic; what is the acid-base disturbance she has?

Answer 13

mixed metabolic acidosis-respiratory alkalosis

the presumption is we don’t know how long ago she ingested + the lethargy might imply the acidosis has taken effect (acutely, salicylate toxicity causes isolated respiratory alkalosis)

Question 14

M. acutely aspirin intoxication what acid-base disturbance?

Answer 14

acutely, salicylate toxicity causes isolated respiratory alkalosis

Question 15

M. aspirin intoxication + lethargy. What acid-base disturbance manifested?

Answer 15

the lethargy might imply the acidosis has taken effect (acutely, salicylate toxicity causes isolated respiratory alkalosis);

Question 16

M. Aspirin toxicity.
arrows.
Na,
K,
Cl,
bicarb,
CO2,
pH???

Answer 16

another Q wants you to select the literal values for mixed:
normal Na,
Normal K,
normal Cl,
low bicarb,
low CO2,
normal or low pH (the metabolic acidosis will eventually “win” and the patient will become severely acidotic, but rarely a Q might give you a pH in the lower end of normal range if patient is in transition).

Question 17

M. Tx for aspirin toxicity?

Answer 17

bicarb

It increases excretion via urinary alkalinization -> cannot reabsorb the oxalate (deprotonated, negative charge) form through the tubular walls.

Question 18

M. 16F + long Hx of depression + taking new medication + large pupils + dry skin + ECG shows QT changes; Dx?

Answer 18

TCA toxicity

Question 19

M. 16F + long Hx of depression + taking new medication + large pupils + dry skin + ECG shows QT changes; Tx?

Answer 19

sodium bicarb

causes dissociation of TCA from myocardial sodium channels -> TCA is basic, not acidic (in contrast to salicylates), so bicarb actually decreases urinary excretion, but the mechanism as an antidote is different; TCAs cause CCC -> coma, convulsions, cardiotoxicity + triad of anticholinergic, anti-alpha-1-adrenergic, and anti-H1- histaminergic side-effects.

Question 20

NBME 10. 10Q.
16 y/o boy + is brought to the emergency department by his mother 30 minutes after a 4-minute episode of generalized shaking of his body. One hour ago, the patient’s friend brought him home after a party, at which time, the patient exhibited unusual behavior and said he was a superhero with the ability to fly. The patient subsequently became unresponsive and the episode began. The friend reports that he saw the patient “smoke weed” at the party 2 hours before the episode. On arrival, the patient is diaphoretic and difficult to arouse. Temp. 37.0°C, pulse is 120/min, RR 24/min, BP 135/95 mm Hg. SpO2 99%. The pupils are 6 mm and sluggishly reactive to light. There is horizontal nystagmus. Use of which of the following substances is the most likely cause of this patient’s symptoms?

Answer 20

PCP

Question 21

NBME 10. 10Q. Phencyclidine (PCP) is an illicit drug that acts on what organ?

Answer 21

central nervous system (CNS) in a variety of ways

Question 22

NBME 10. 10Q. PCP
It antagonizes N-methyl-D-aspartate receptors leading to excitatory neurotransmitter release, inhibits the reuptake of dopamine, norepinephrine, and serotonin, and stimulates α-adrenergic receptors.

Answer 22

.

Question 23

NBME 10. 10Q. Acute PCP intoxication can lead to what psych/neuro CP?

Answer 23

psychosis, bizarre behavior, agitation, aggression, nystagmus, and ataxia.

Question 24

NBME 10. 10Q. PCP
Patients may be diaphoretic, tachycardic, and hypertensive as a result of sympathomimetic effects

Answer 24

.

Question 25

NBME 10. 10Q. Chronic PCP abuse can lead to what CP? neural/psych

Answer 25

depression, psychotic symptoms, memory loss, and dysarthria

Question 26

NBME 10. 10Q. PCP What need to control in the first place in Mx?

Answer 26

Control of psychomotor agitation is the first step in management of patients with PCP intoxication for the safety of the patient and medical staff.

Question 27

NBME 10. 10Q. PCP MANAGEMENT?

Answer 27

Chemical sedation with benzodiazepines such as intramuscular lorazepam or midazolam can be administered to control symptoms.

Question 28

NBME 10. 10Q. PCP. once given medications BZD --> what can evaluate next?

Answer 28

Once a patient is adequately sedated, further evaluation can be completed to assess for traumatic injuries or complications of PCP intoxication such as rhabdomyolysis, hyperthermia, and hypertension.

Question 29

NBME 10. 10Q. In severe cases, PCP intoxication can cause? neuro

Answer 29

seizures, encephalopathy, or a comatose state, which may necessitate emergent management, intubation, and supportive care.

Question 30

NBME 10. 10Q. kitas ats. Diazepam (Choice A), a benzodiazepine, and ethanol (Choice B) are CNS depressants that, in toxic doses, can cause .....CP?

Answer 30

slurred speech, ataxia, emotional lability, and memory lapses.

Question 31

NBME 10. 10Q. kitas ats. marijuana. CP?

Answer 31

is a hallucinogen that causes euphoria, paranoia, hallucinations, cognitive slowing, conjunctival injection, and dilated pupils.

Question 32

NBME 10. 10Q. kitas ats. Methamphetamine. CP?

Answer 32

is a CNS stimulant that causes euphoria and increases sympathetic tone, leading to tachycardia, hypertension, pupillary dilation, and restlessness. Because of increased synaptic dopamine, hallucinations and paranoia can occur.

Question 33

NBME 10. 86Q. A 3-year-old girl is brought to the emergency department after her mother found her in the kitchen next to an open bottle of drain cleaner that had been stored under the sink. The bottle was still almost full, but some of its contents were spilled on the patient's clothes and on the floor. On arrival, she is alert, crying, and drooling but in no respiratory distress. Her pulse is 120/min, respirations are 30/min, and blood pressure is 95/70 mm Hg. The mouth and oral mucosa is bright red, but there are no ulcers in the oropharynx. The lungs are clear to auscultation. Abdominal examination shows no abnormalities. The extremities are well perfused. An x-ray of the chest shows clear lung fields and normal cardiac silhouette and mediastinum. Which of the following is the most appropriate next step in management?

Answer 33

Esophagoscopy

Question 34

NBME 10. 10Q. drain cleaners. Drain cleaners are a common cause of caustic ingestions in children. They contain sodium and potassium hydroxides, alkali that are proton acceptors and strong nucleophiles.

Answer 34

.

Question 35

NBME 10. 10Q. drain cleaners. CP?

Answer 35

Alkali ingestion leads to liquefactive necrosis, lactic acidosis, and tissue penetration and ulceration. It can cause chemical burns and ulcerations of the tongue, airway, and esophagus, resulting in stridor, hoarseness, vomiting, and drooling. If severe, esophageal perforation can ensue, leading to free air in the mediastinum, known as Boerhaave syndrome, a surgical emergency.

Question 36

NBME 10. 10Q. drain cleaners. Tx

Answer 36

Treatment is initially focused on supportive measures including airway management and fluid resuscitation.

Question 37

NBME 10. 10Q. drain cleaners. Visible lesions in the oropharynx increase the likelihood of distal gastrointestinal lesions. Patients should be emergently evaluated with esophagoscopy (endoscopy) to assess for visceral injury and guide management.

Answer 37

.

Question 38

NBME 10. 10Q. drain cleaners. for severe cases what need to administrate?

Answer 38

For severe injuries, treatment involves steroid administration.

Question 39

NBME 10. 10Q. drain cleaners. Should we give activated charcoal?

Answer 39

Activated charcoal is contraindicated because of the coating of ulcerated mucosa, potential for extraluminal spread into the mediastinum, and impairment of visualization on endoscopy. Administration of activated charcoal (Choice B) would be unlikely to be beneficial and would not be safe in a patient who is drooling and has likely tissue injury secondary to alkali ingestion. Charcoal, if aspirated, can be harmful to the pulmonary parenchyma and cause aspiration pneumonitis. In contrast, other toxic ingestions may required charcoal.

Question 40

NBME 10. 10Q. drain cleaners. gastric lavage (Choice E) was a common gastric decontamination procedure for oral toxic ingestions that is no longer widely recommended.

Answer 40

.

Question 41

NBME 10. 10Q. drain cleaners. barium swallow - in dysphagia

Answer 41

.