Callthemedic Posted April 20, 2006 Posted April 20, 2006 Hubby was out of state And this "She is taking atenolol, norvasc, quinine, oxycontin, robaxin, motrin, methadone, lasix and Kdur. FS is 106. 114/68 68 14 98.2." Oxycontin Methadone She is cucko for coaco puffs. I suppose the pt hx will be "sketchy". Histironic dx seems to fit nicely, so that is not it. She cannot voluntarily control her pupils so I will ask..........has she lost tone anywhere else?
AZCEP Posted April 20, 2006 Posted April 20, 2006 Facial droop? Arm drift? Slurred speech? Doesn't quinine cause a vertical vision loss? Can she move her eyes through the four points when told to? Maybe Optic nerve impingement?
chbare Posted April 20, 2006 Posted April 20, 2006 AZCEP, I am not sure about the vertical vision loss. Quinine is toxic to the retina. I think retinal artery spasm is the current theory behind the S/S. S/S include; loss of visual fields, scotomata, progression to complete blindness, and pupil dilation. I think the vision loss starts around 9-10 hours following ingestion. However, I would also expect other S/S. The confusion can be related to quinine but are there C/O N/V, tinnitus, HA, or hearing loss. From a prior post we learned that she does not C/O HA. We have put her on the monitor and I would be curious to see what her Q-T interval is. Good call on checking for other Nero S/S and working the intracranial pathology route. Callthemedic, I agree, this lady may be a little "cuko for coca puffs," and she is on some pretty potent medications. RaceMedic, good call on the script and additional background. Too bad this isn't the land of OZ and I could sprinkle magic fairy dust and produce a tonometer, slit lamp, portable lab, 12 lead ECG, and CT scanner!!! On a side note, HX of HEP C. is she getting interferon TX? I have heard of people developing retinal hemorrhage after receiving interferon. Is she jaundiced? Could some of this be related to encephalopathy? Ammonia LV? Take care everybody, chbare.
Callthemedic Posted April 20, 2006 Posted April 20, 2006 AZCEP, I am not sure about the vertical vision loss. Quinine is toxic to the retina. I think retinal artery spasm is the current theory behind the S/S. S/S include; loss of visual fields, scotomata, progression to complete blindness, and pupil dilation. I think the vision loss starts around 9-10 hours following ingestion. However, I would also expect other S/S. The confusion can be related to quinine but are there C/O N/V, tinnitus, HA, or hearing loss. From a prior post we learned that she does not C/O HA. We have put her on the monitor and I would be curious to see what her Q-T interval is. Good call on checking for other Nero S/S and working the intracranial pathology route. Callthemedic, I agree, this lady may be a little "cuko for coca puffs," and she is on some pretty potent medications. On a side note, HX of HEP C. is she getting interferon TX? I have heard of people developing retinal hemorrhage after receiving interferon. Is she jaundiced? Could some of this be related to encephalopathy? Ammonia LV? Take care everybody, chbare. The HEP and methadone make me think IV drug abuse. The grocery list of meds, attention/drug seeking behavior, hypochondriasis. The addition of oxycontin to the list was like the "cherry on top". That's why I would lean toward a psych case. It is too easy to say she's just fruit loops because something is interfering with the optic nerve distal to the chiasma. Could be what's left of her brain cells making it all up but I don't have the experience to call it. The VS seem too stable to be using........but.......the liver isn't metabolizing whatever she is taking. There is a build-up of something, there has to be. She just can't properly process or eliminate those metabolites. What about inspecting the skin where drug users hide tracks?
chbare Posted April 20, 2006 Posted April 20, 2006 Callthemedic- I see your point. This patient has allot of different problems aside from the confusion and blindness. I have issues with the dilated pupils. This tells me possibly something metabolic (drug metabolites) or structural. I am leaning toward some kind of substance build up like you. I think it is a good idea to look for fresh track marks, maybe she is using drugs again If she is, try to find out what. I am with AZCEP's thinking. Get a thorough neurological exam (As the patients condition allows.) and try to rule out intracranial pathology the best we can. Take care, chbare.
Callthemedic Posted April 20, 2006 Posted April 20, 2006 Yes, "multi-factorial" lol The vs are too "level". There doesn't seem to be any other neurogenic effect. If she is blind it is resonable that she may have fell and "bounced the coconut". She has been alone.
chbare Posted April 20, 2006 Posted April 20, 2006 Callthemedic, Hard to say. I hope ERDoc will give us some more info. Or, perhaps were overlooking something. Take care, chbare.
ERDoc Posted April 21, 2006 Author Posted April 21, 2006 Sorry I haven't answered any posts in a while. There was some good discussion going on and I didn't want to pollute with more info. The husband says that the pt has been clean for almost 5 years. He says that this is her normal mental state. He left on Friday and came back today (Monday). He normally handles her meds, but since he had to leave he left them in one of those pill bottles that have the days of the week on them. The quinine script is not new, she has been using it for leg cramps every since the back injury. Ethnicity is whatever you want it to be (she does not have G6PD). AZCEP: There is no facial droop, arm drift or slurred speech. How would optic nerve compression limits your ability to move your eyes? chbare: I will give you your pixie dust. EKG is unremarkeable, CT head normal, tonometry reveals IOPs of 10 on the left and 12 on the right. What are you looking for with a slit lamp (there is no corneal abrasion or hyphema)? She was on interferon about 7-10 years ago, but has not followed up with her GI doc, but the husband thinks her last set of labs were normal. There is no jaundice. Her ammonia level is normal. Even with the pixie dust, the quinine level is a send out lab and has to go to a lab 2000 miles away (which you find out after a 30 minute discussion with the lab that you have in your ambulance). There are no track marks that you can see. Her neuro exam is pretty normal, execpt for the blindness (she does not respond when you present a threating stimulus to her (you make it look like you are going to hit her)). Hope this helps, and it actually reminded me of another case (see you in the next thread).
chbare Posted April 21, 2006 Posted April 21, 2006 Hmmm... Well, I still cannot rule out conversion. I guess I should have asked this question much earlier, is the pupil dilation a new thing. Thanks, chbare.
ERDoc Posted April 21, 2006 Author Posted April 21, 2006 Hmmm... Well, I still cannot rule out conversion. I guess I should have asked this question much earlier, is the pupil dilation a new thing. Thanks, chbare. Husband is not sure, but he doesn't remember them being so big. Do you really think at this point that you can feel comfortable to a physchiatric dx? Would you feel comfortable sending this wman home if you truly believe it to be a psychiatric cause?
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