218.A 19-year-old man is brought to the ED by EMS after he was found
lying on the floor at a dance club. EMS states that the patient seemed uncon-
scious at the dance club but as soon as they transferred him onto the gurney
he became combative. Upon arrival in the ED, his BP is 120/65 mm Hg, HR
is 75 beats per minute, temperature is 98.9°F, RR is 12 breaths per minute,
and oxygen saturation is 98% on room air. On physical examination, his
pupils are midsized, equal, and reactive to light. His skin is warm and dry.
Lung, cardiac, and abdominal examination are unremarkable. As you walk
away from the bedside, you hear the monitor alarm signaling zero respira-
tions and the oxygen saturation starts to drop. You perform a sternal rub
and the patient sits up in bed and starts yelling at you. As you leave him for
the second time, you hear the monitor alarm again signal zero respirations.
You administer naloxone, but there is no change in his condition. Which of
the following is most likely the substance ingested by this patient?
a. γ-Hydroxybutyrate (GHB)
b. Diazepam
c. Cocaine
d. Phencyclidine (PCP)
e. Heroin
219.A 43-year-old woman presents to the ED with a 3-week history of
intermittent headache, nausea, and fatigue. She was seen at her private doc-
tor’s office 1 week ago along with her husband and children, who also have
similar symptoms. They were diagnosed with a viral syndrome and told to
increase their fluid intake. She states that the symptoms began approximately
when it started to get cold outside. The symptoms are worse in the morning
and improve while she is at work. Her BP is 123/75 mm Hg, HR is 83 beats
per minute, temperature is 98.9°F, and oxygen saturation is 98% on room air.
Physical examination is unremarkable. You suspect her first diagnosis was
incorrect. Which of the following is the most appropriate next step to con-
firm your suspicion?
a. Order a mono spot test
b. Perform a nasal pharyngeal swab to test for influenza
c. Consult psychiatry to evaluate for malingering
d. Order a carboxyhemoglobin (COHb) level
e. Order a lead level
236 Emergency Medicine