CC: confusion, altered mental status

HPI: 16yoF with no PMHx brought in by parents for altered mental status and concern for ingestion. Police were called when patient found asleep and difficult to arouse on the Metro at 11pm on Saturday night. Patient arousable and able to walk off the Metro but somnolent and confused with unsteady gait when police arrived. Police called patient’s parents, who picked her up and brought her to the ED. Dad reports patient endorsed marijuana use that evening. Prior to leaving the house earlier that evening patient was at her baseline with no symptoms/complaints. Parents concerned for ingestion and requesting a “full drug workup of blood, urine, and hair”.

ROS (per parents initially, then confirmed by patient later):
GENERAL: no fever, chills, fatigue, weight change
HEENT: no trauma; no eye pain, redness, discharge; no vision change; no congestion or rhinorrhea; no throat pain
NECK: no neck pain
CV: no chest pain, no palpitations, no syncope
RESPIRATORY: no cough, no wheeze, no SOB or increased WOB
GI: no abdominal pain, no N/V/D
GU: no dysuria, hematuria, discharge; no pain, swelling, pruritus
NEURO: +AMS, no headache, no vision change, no weakness, numbness, tingling; no gait change; no seizures
MSK: no muscle pain or weakness; no joint swelling, redness, pain
SKIN: no rash, no petechial or purpura
ENDOCRINE: no polyuria, polydipsia, or hx/o diabetes
PSYCH: no history of depression, bipolar, anxiety

Question 1: Given that information, and before examining the patient, what workup would you have in mind? Check all that apply:

PHYSICAL EXAM (~4hrs after police initially called):
VS: HR 75 RR 16 O2 100% on RA BP 105/75

GA: awake, alert, interactive, well-nourished well-developed, no acute distress
HEENT: NCAT, PERRLA (4mm to 2mm and brisk), no nystagmus, vision grossly intact, TM clear, nares patent, OP clear
NECK: supple, no nuchal rigidity, no cervical LAD
CV: normal S1/S2 RRR, no m/g/r, 2+ peripheral pulses, CR <2sec
LUNGS: CTAB, no w/r/r, no tachypnea, no increased WOB
ABD: S/NT/ND, +BS, no HSM
MSK: MAEW and symmetrically, no deformity/swelling/tenderness
BACK: no midline TTP, no step-offs
SKIN: No rash, no petechia
NEURO: CN II-XII intact, SILT, 5/5 strength BUE/BLE proximal and distal muscle groups, 2+ reflexes, no dysmetria, normal heel-to-shin, normal finger-to-nose, no pronator drift, normal Romberg, normal gait
PSYCH: cooperative, appropriate, no SI/HI/AVH

You speak to patient privately. She denies ingestion of any ETOH, illicit drugs (including marijuana), or OTC drugs of any kind that evening. She says she was just asleep on the Metro. Denies concern for ingesting anything without her knowledge. She has no complaints or concerns and does not want blood work done or to give urine.

Question 2: What work up, if any, would you do after your physical exam? Check all that apply:

You inform parents of their daughters reassuring exam and inform them that no lab work or imaging workup is indicated at this time. Despite their daughter’s endorsement of marijuana use they insist that their daughter never uses drugs or ETOH, and if she was intoxicated earlier in the evening it was because someone drugged her. They insist blood and urine drug tests be performed, or that blood and urine be obtained and given to them to take with them on discharge to have tested elsewhere.

Question 3: After talking with the parents you decide to (choose one):

You consult Social Work to provide family with substance abuse resources and then discharge patient home.

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