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Med-Challenger FM Career
Comprehensive Review and Assessment for
Practicing
Family Physicians
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Issue: February 15, 2007
Case: Drug, Electrolyte, and Metabolic Problems
Taken from
Med-Challenger FM Career
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Question:
A 75-year-old woman, accompanied by her daughter, arrives for
evaluation. The patient, normally alert, oriented, and fully
functional, is obviously experiencing visual and auditory
hallucinations. She is agitated and fearful. The patient's
neighbor contacted her family when she was observed trying to
back her automobile out of a garage. She appeared disoriented at
that time, and did not seem to recognize her neighbor.
Her medical history includes chronic hypertension, irritable
bowel syndrome, and insomnia. Her medications include an
over-the-counter antacid, Lomotil for diarrhea, a diuretic, and
diphenhydramine for sleep.
She has a temperature of 100.9, heart rate of 160, and blood
pressure of 180/110. Her skin is hot, dry and flushed. Mucus
membranes are dry. Pupils are dilated bilaterally. WBC is
14,800.
Her ECG is displayed to the right (Click here to enlarge
Image 1). Considering
the history and clinical findings, what is the most likely
diagnosis?
- senile dementia
- acute psychosis
- sepsis
- anticholinergic toxicity
- ketoacidosis
Answer:
D
Remediation:
This patient is taking two medications containing
anticholinergic agents, Lomotil (with atropine) and
diphenhydramine. Atropinism has been caused by normal doses of
atropine and homatropine eye drops. The central nervous system
actions of atropine and atropine-like drugs are attributed to
the blockade of muscarinic synapses.
Bronchodilator inhaler overuse can produce similar symptoms.
Commercially available teas (thorn apple) and teas prepared with
plants containing atropine have produced serious intoxication.
Leukocytosis may occur, confusing the diagnosis.
A diagnosis of dementia or psychosis should be considered only
after medical causes are excluded.
ECG findings associated with atropine or anticholinergic
toxicity may include:
- Tachycardia
- Atrial arrhythmias
- Wandering pacemaker
- Second degree AV block
- AV dissociation
About the Image(s):
Image 1:
ECG: Sinus Tachycardia and Left Ventricular Hypertrophy
The ECG of this 75-year-old woman shows:
- Sinus tachycardia, rate 163
- One atrial premature complex or ventricular premature
complex with fusion, which occurred during recording of the
lateral chest leads
- Probable left ventricular hypertrophy with ST-T
repolarization abnormalities
- Borderline low voltage in the frontal leads
- Poor R wave progression, possibly due to left
ventricular hypertrophy
- Marked anterior ST segment elevation, possibly due to
left ventricular hypertrophy, tachycardia
Image 2: Typical Normal Adult ECG for Comparison
This ECG of a 53-year-old male shows:
- Normal sinus rhythm, rate 87
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