RT Book, Section
A1 Hoffman, Robert S.
A1 Howland, Mary Ann
A1 Lewin, Neal A.
A1 Nelson, Lewis S.
A1 Goldfrank, Lewis R.
SR Print(0)
ID 1108439031
T1 Case Study 7
T2 Goldfrank's Toxicologic Emergencies, 10e
YR 2015
FD 2015
PB McGraw-Hill Education
PP New York, NY
SN 9780071801843
LK accessemergencymedicine.mhmedical.com/content.aspx?aid=1108439031
RD 2024/04/19
AB HistoryA  45  year-old  man  presented  to  the  hospital  complaining  of  hand  and  foot  pain  so  severe  that  he  was  unable  to  drive  his  car.  The  man  had  been  well  until  several  weeks  earlier,  when  he  began  having  gastrointestinal  distress  that  he  thought  was  “heartburn”  and  mild  weight  loss,  which  he  attributed  to  his  dyspepsia.  He  denied  fever,  chills,  nausea,  vomiting,  or  diarrhea.  He  also  related  that  on  the  day  prior  to  admission  he  was  unable  to  eat  a  meal  because  he  thought  it  was  spoiled  after  taking  a  few  bites.  The  next  morning,  while  driving,  he  pulled  off  the  road  and  phoned  emergency  medical  services.  He  was  taking  no  medications  and  had  no  allergies.Physical  ExaminationIn  the  emergency  department,  the  patient  appeared  well  developed  and  well  nourished,  but  was  complaining  of  severe  pain  in  his  hands  and  feet.  Vital  signs  were:  blood  pressure,  124/68  mm  Hg;  pulse,  92  beats/min;  respiratory  rate,  14  breaths/min;  oral  temperature,  98.6°F  (37.0°C);  oxygen  saturation,  99%  on  room  air;  and  a  rapid  reagent  glucose  of  128  mg/dL.  Physical  examination  was  notable  for  pupils  that  were  equal,  round  (4  mm),  and  reactive  to  light;  normal  extraocular  movements;  and  the  absence  of  nuchal  rigidity.  His  chest  was  clear  to  auscultation,  and  his  heart  sounds  were  normal.  His  abdomen  was  soft  and  nontender,  with  normal  bowel  sounds  and  no  organomegaly.  He  was  awake,  alert,  and  oriented  with  normal  symmetrical  strength  and  brisk  reflexes.  Although  he  complained  of  pain  in  his  hands  and  feet,  his  two-point  discrimination,  proprioception,  and  vibration  sensation  appeared  normal.  His  gait  was  slightly  wide  based  and  slow,  but  this  was  thought  to  be  secondary  to  pain.  Cranial  nerves  II  through  XII  appeared  intact,  and  cerebellar  testing  was  normal.Immediate  Assessment  and  ManagementAlthough  the  patient  appeared  uncomfortable,  there  was  no  perception  of  an  immediate  life  threat.  An  intravenous  line  was  inserted,  and  blood  was  obtained  for  a  complete  blood  count,  electrolytes,  and  liver  function  testing.  A  urinalysis  was  requested  as  was  an  electrocardiogram  and  a  chest  radiograph.  Acetaminophen  was  given  for  analgesia,  without  relief.  The  patient  required  parenteral  opioids  to  diminish  his  pain,  although  he  noted  that  the  distribution  had  spread  to  include  most  of  his  legs  and  arms.  He  also  became  somnolent,  and  it  was  unclear  if  the  ensuing  somnolence  was  opioid  related.What  Is  the  Differential  Diagnosis?The  major  presenting  symptom  in  this  case  is  a  painful  sensory  peripheral  neuropathy  (an  uncommon  clinical  manifestation)  associated  with  gastrointestinal  symptoms  (a  common  manifestation).  Considerations  include  a  variety  of  metabolic  and  endocrine  disorders,  infections,  medications,  and  toxins.  Severely  painful  symmetrical  paresthesias  are  fairly  uncommon  and  the  differential  diagnosis  is  limited.  Considerations  include  freezing  injury  such  as  frostbite  (Chap.  30),  proximity  to  radioactive  materials  (Chap.  134),  and  topical  exposure  to  hydrofluoric  acid  (Chap.  107).  A  list  of  xenobiotics  that  can  cause  such  findings  following  ingestion  is  found  in  (Table  CS7–1).What  Immediate  Diagnostic  and  Therapeutic  Interventions  Are  Indicated?In  addition  to  the  above  evaluation,  a  diagnosis  of  encephalitis  was  considered  when  the  patient  became  somnolent,  and  a  computed  tomography  (CT)  scan  of  the  head  was  obtained  without  ...