NARESH MULLAGURI MDRESIDENT PHYSICIAN

UNIVERSITY OF MISSOURICOLUMBIA, MISSOURI

FRIDAY CASE CONFERENCEMODERN DISEASES IN THE ERA OF

POLYPHARMACY

INTERNAL MEDICINE CONSULT FOR EVALUATION OF SEIZURES

Why did you come to the Hospital?

“. . . . I overdosed on my Effexor pills to kill myself. My wife called 911 and they took me to the Hospital.”

How many pills did you took?

I don’t know. I stopped taking all my medications for the past few months and I think I took a whole bottle of pills.

What happened after that?

My wife found out that I overdosed again (6 th time with this attempt included), as I was confused and fell down from a chair and was told that I had a seizure, she called 911 and they took me to Texas county medical center day before yesterday and from there I came to the VA via ambulance yesterday.

Do you remember anything that happened in the outside hospital?

I don’t know. I got my senses back in VA. My wife went home from there and I haven’t seen her.

HPI CONTINUED…Why did you hurt yourself?

I was depressed. I was good for nothing.

And he stopped responding and the rest of the interview went on with occasional words, gestures and head nods. Denied any headache, trauma to the head and neck, prior history of seizures, infections of brain or the coverings of brain, febrile seizures as a child, uneventful perinatal course with appropriate milestone development. Denied any memory of the seizure he had. Denied having any vision, speech problems. Denied any incontinence of bladder and was on a Foley’s catheter at the time of interview.

Said he is unable to use his legs because they are stiff and painful and more weak than usual. Cramping pain in the abdomen with no nausea or vomiting. Increased sweating for the past 2 days. He had tremors in bilateral upper extremities seems to be better today. No appetite and denied any weight loss, no recent use of medications or street drugs. At baseline he was wheel chair bound since January and from then his wife helps with the transfers and other ADLs at home. He had colostomy because of intestinal fistula from complicated Clostridium infection in the recent past which drained a lot of yellowish green fluid in the past 2 days but got better on the day of interview.

Digging the medical record.

He saw his PCP in November 2014 and since then stopped all the medications including Insulin(latest HbA1c is 12.8), overdosed on Coumadin in January 2015 which ended up in a complicated hospital course landing in respiratory failure, HCAP and had tracheostomy which was weaned off lately but still got the stoma.

Initially code stroke was activated in the outside hospital and CT scan of the Brain was negative for Bleeding and by that time patient was conscious and admitted overdosing on Venlaflaxine. He was resuscitated with fluids based on toxicology guidelines and patient wished to be transferred to the VA for further management .

PAST MEDICAL HISTORY=====================COPDMultiple Suicidal attempts, Anxiety and DepressionObstructive Sleep Apnea on CPAP with poor complianceMorbid ObesityHyperlipidemiaDrug induced Parkinsonism in the past from HaloperidolCongestive Heart failureDeep vein thrombosis not on anticoagulation at present due to recent overdoseEnterocutaneous fistulaRecurrent Clostridium difficile colitisHypothyroidismStrokeHx of AlcoholismBilateral sacral decubitus ulcers with no Osteomyelitis

FAMILY HISTORY==============Diabetes MellitusDepressionSOCIAL HISTORY==============

Lives with wife, Disabled. Documented history of Alcohol abuse but quit >10years ago. Prior nicotine dependence, Quit several years ago. Unknown drug use history. After retiring from air force ( served during Persian gulf war) he used to work as taxi driver.ALLERGIES==========Sulpha drugsMEDICATIONS============

Tylenol, Aripiprazole, Maalox, Aspirin, Atorvastatin, Sinemet 25/250 TID, Vitamin B12, Ferrous sulphate, Finasteride, Formoterol, Furosemide, Insulin, Ipratropium, Levothyroxine, MgO, Metformin, Metoprolol, Milk of Magnesia, Mirtazepine, Ondansetron, Pantoprazole, KCl, Topiramate 100mg QHS, Venlaflaxine 150mg SA Daily

DIFFERENTIAL DIAGNOSISMetabolic/Toxic:

Serotonin Syndrome

Neuroleptic Malignant syndrome

Amphetamine/Cocaine overdose

Sedative or Hypnotic withdrawal

Anticholinergic toxicity

Infectious causes:

Meningoencephalitis - HSV

Neoplastic:

Limbic encephalitis

Endocrine:

Thyroid Storm

Psychiatric:

Catatonia/Hysteria

VITAL SIGNS• Temperature: 97.8

• PR: 66

• RR:21

• BP: 100/57 mm of Hg

• BMI: 47

• Pain 5/10

PHYSICAL EXAMINATIONGENERAL : A morbidly obese white male who looks apathetic, Somnolent but arousable to voice. GCS – 15, not in distress.

HEENT: normocephalic and atraumatic, No conjunctival congestion, pallor or icterus, mucous membranes are moist, neck is supple but short with restriction of movement to the extremes due to nuchal pad of fat. Tracheostomy stoma opened with no secretions.

CARDIOVASCULAR: regular rate and rhythm, Telemetry didn’t show any tachycardia or arrhythmias, S1, S2 heard on auscultation but very low amplitude, No murmurs audible

RESPIRATORY: Diminished air entry with minimal chest expansion, clear in the infra clavicle and infra-axillary regions. Unable to auscultate the back.

ABDOMEN: soft, colostomy draining yellowish green semi formed stool (output of 600ml since midnight, prior 2 days 1000-1200ml daily). High pitched and rapid bowel sounds in all the quadrants. Mild tenderness appreciated to deep palpation.

EXTREMITIES: bilateral pedal edema with redness and chronic venous stasis pigmentation, no spontaneous movements noticed. No bruises noticed.

SKIN: Bilateral decubitus ulcers over the sacrum, stage 2, No acral cyanosis or clubbing.

PSYCHIATRY: flat affect, depressed, still expressed suicidal ideation, Denied any visual or auditory hallucinations

NEUROLOGICAL EXAMINATIONMENTAL STATUS: somnolent with less attention span but oriented to person, place, situation not to time. Slow to respond, , Patient nods yes and no to questions and gives short single word answers. Fluent speech with good comprehension. No dysarthria.

CRANIAL NERVES: visual fields are intact to confrontation, EOM were intact to pursuit and volitional movements. No nystagmus, Facial sensations are intact, No facial asymmetry, able to close his eyes tightly, Able to raise eyebrows, Puff up cheeks, Soft husky voice, hearing was intact to conversation, Tongue protrudes to midline, uvula is in midline and elevates symmetrically.

MOTOR EXAM: Tone increased in all the extremities predominantly in the lower extremities. Bradykinesia present, fine tremor noted in bilateral upper extremities noticed worst when performing FTN testing. Strength is 4-/5 in bilateral upper extremities and 4-/5 in the bilateral hip flexors and extensors, knee flexors and extensors and 2/4 in bilateral plantar flexors and extensors. DTRs 2+/4 in bilateral biceps, triceps and 1+/4 in bilateral brachioradialis, 2+/4 bilateral knees and 0/4 in bilateral ankles. Plantars were mute bilaterally.

SENSORY EXAM: impaired to pin prick in all the four extremities with distal graded sensory loss in bilateral lower extremities upto lower 1/3 of legs. Proprioception is lost upto toes bilaterally.

COORDINATION: unable to finish FTN due to subjective weakness and somnolence. Able to perform rapid alternating movements like finger tapping in a slow fashion.

GAIT: deferred due to weakness and rigidity.

INVESTIGATIONS

Outside Hospital : Elevated CPK, Anion gap metabolic acidosis, Myoglobinuria, Elevated Creatinine

Radiology: Non contrast CT was unremarkable for any Bleed or hypo densities. No mass lesions or midline shift. Glucose is 170. UDS negative for amphetamines, cannabinoids, opiates, phencyclidine

LABS

DIAGNOSIS : SEROTONIN SYNDROME

NEJM: Edward W Boyer, MD, PhD MPH 2005;352:1112-1120, March 17, 2005

SEROTONIN SYNDROME AND RESIDENCY TRAINING IN USA

DO NO HARM

SEROTONIN BIOSYNTHESIS AND METABOLISM

IMPORTANT DRUG INTERACTIONS

NEJM: Edward W Boyer, MD, PhD MPH 2005;352:1112-1120, March 17, 2005

PATHOPHYSIOLOGY

NEJM: Edward W Boyer, MD, PhD MPH 2005;352:1112-1120, March 17, 2005

MANAGEMENT

THANK YOU

My sincere thanks to Dr. Govindarajan