EM Forum Case #165 "UDS"
by Charlene Babcock, MD, FACEP  

At the 7AM turnover, you are signed out a 22 y/o female who is ‘likely high on drugs’.

EMS notes they were called for altered mental status, and on their arrival she was disoriented and crying out, and they were having problems getting her to answer simple questions. She was in the upstairs bathroom, and there was a party going on downstairs. She denied any drug or alcohol ingestion, but they felt she was high on drugs based on ‘how she is acting’.

The previous doc notes the urine drug screen is pending. He notes she will answer questions, but not consistently. At times she just rocks back and forth and is very agitated, but then she goes to sleep. She is easily arousable. She has vomited several times. He is having a hard time getting a history from the patient, but her sister and boyfriend are in the room. The previous ED doctor did order some Ativan and Zofran.

After turnover, you approach the pateins room and find her sitting on a chair with her chest, head and arms on the cot, lights off, towel over her head. Her sister and boyfriend are in the room. Her sister tells you there was a party at their house, but the patient did not participate. She actually went to bed early, and then woke up once to come down stairs and ask them to turn the music down. About 1 hour later her boyfriend heard her moaning in the bathroom. She was vomiting and when he tried to talk to her, she couldn’t answer. “It’s like she was trying to say the words, but they wouldn’t come out!” he added. “I could tell she was really frustrated when she was trying to talk, then eventually she would scream in frustration.“

During your interview, she has no word finding problem, has clear speech, but speaks slowly. Previous to this morning she was fine, ROS (review of systems) negative prior to this AM. After the event in the bathroom, she seemed to have times when she could talk, and she complained of a headache and ‘not feeling right.’ She had vomited several times, no blood or coffee grounds. She notes the light bothers her, but other ROS negative. She denied any ingestion.

PMH: Vaginal infection on Metronidazole, no other medical problems.

SH: Smoker, no drug or alcohol abuse, works in a shipping company.

PE: WDWN female,lying quietly half prone on the cot. A towel is over the top of her head.
100/60 HR=55 RR=18 Temp=98.4 Sat=98%

HEENT: Photophobia is noted, but pupils are round and reactive. She cannot tolerate a fundoscopic exam. Otherwise negative exam, neck supple

Heart/lung/abdomen/skin exam negative

Neurologic: Cranial nerves, motor, and sensory exam normal. Mental status: Oriented x 3, speech slow but clear. Gait wide based but Romberg negative. Finger to nose test is normal. Negative Kernigs and Brudzinski signs, Babinski downgoing, and slight hyperreflexia with 3 beats of clonus at ankle bilaterally.

Urine drug screen is negative.

A CT scan is ordered along with a basic metabolic panel and CBC. Patient is more bradycardic with heart rate down to 38 at times (sinus bradycardia).