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Alcohol
4%
4/103
Cocaine
7%
7/103
Diphenhydramine
17%
17/103
Haloperidol
69%
71/103
Marijuana
2%
2/103
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This patient is presenting with hypertension, irritability, dilated pupils, and warm/sweaty skin which is concerning for a sympathomimetic overdose, such as cocaine. Cocaine use causes behavioral changes including euphoria or blunted feelings, hypervigilance or hypersensitivity, heightened anxiety or irritability, and impaired judgment. Findings can include dilated pupils, chills or sweating, nausea, chest pain (can worsen Prinzmetal angina secondary to cocaine-induced vasospasm), increased bowel sounds, warm/sweaty skin, and seizures. Long-term cocaine use can lead to weight loss and other physical manifestations including nasal septal perforation secondary to arterial contraction necrosis. Patients need to be observed until they are sober. Treatment of hypertension can include alpha-blockers like phentolamine. Treatment of chest pain in this condition can include benzodiazepines and calcium channel blockers (such as diltiazem); however, a STEMI should still be worked up and treated like a STEMI versus being thought of as secondary to vasospasm. Cocaine withdrawal can present with depression and is associated with chronic use. Incorrect Answers: Answer 1: Alcohol intoxication presents with amnesia, ataxia, stupor/somnolence, emotional lability, slurred speech, and minor respiratory depression. Answer 3: Diphenhydramine overdose can cause an anticholinergic toxidrome which presents with dry/flushed skin, confusion, constipation, dilated pupils, tachycardia, and urinary retention. This patient's sweaty skin and hypertension are more consistent with cocaine abuse. Answer 4: Haloperidol can cause an acute dystonic reaction (painful muscle contraction), akathisia (restlessness), and tardive dyskinesia (repeat stereotypical movements with long-term use). Answer 5: Marijuana intoxication presents with euphoria, anxiety, disinhibition, paranoid delusions, perception of slowed time, impaired judgment, conjunctival injection, and increased appetite. Bullet Summary: Cocaine overdose presents with irritability, hypertension, dilated pupils, increased bowel sounds, and warm/sweaty skin.
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