Comprehensive Evaluation Exam 1

Question 1

Questions to ask while taking history of poisoning

Answer 1

• Who, What, When, Where, Why, How?
• Symptoms?
• Quantity/Pill Counts?
• Co-ingestants?
• Co-conspirators and other Liars?
• Prior management?
• Preconceived notions-”my neighbors sprayed….”
• Pre-existing medical conditions/allergies?

Question 2

anion gap calculation

Answer 2

Anion gap = (Na+) - [(Cl-) + (HCO3)]

Question 3

When do you check an osmolar gap?

Answer 3

if anion gap is elevated

Question 4

normal anion gap value

Answer 4

8-12 mEq/L

Question 5

What are things that elevate anion gap?

Answer 5

CATMUDPILES
• Cyanide 
• Alcohol 
• Toluene 
• Methanol 
• Uremia 
• DKA 
• Paraldehyde 
• Isoniazid/Iron
• Lactate 
• Ethylene Glycol 
• Salicylate/Strychnine

Question 6

osmolality equation

Answer 6

2(Na+) + glucose/18 + BUN/2.8

Question 7

normal osmolality value

Answer 7

290 mOsm/L or less

Question 8

osmolar gap

Answer 8

• Difference between calculated and Observed

- Normal gap <= 10 mOsm/L

Question 9

What are things that elevate osmolar gap?

Answer 9

• Ethanol
• Isopropanol
• Methanol
• Ethylene glycol

Question 10

What are limitations in drug screens?

Answer 10

• Limited to 6-7 classes of drugs of abuse
• False positives
• Negative screenins can happen due to levels being lower than detection
• Post mortem levels not reliable
• Lethal levels vary
• Serum levels does not correlate with outcome / intent

Question 11

Important false positives / negatives

Answer 11

• Diphenhydramine- TCA
• Dextromethorphan- PCP, opiates
• Pseudoephedrine- methamphetamine
• Marijuana may test positive for up to six weeks after heavy use.
• Spice and bath salts do not show up on routine testing.
• Most plants do not show up on routine testing.
• Some narcotics like methadone won’t show up as an opiate

Question 12

clinical effects of anticholingerics (this is the one he wanted us to know)

Answer 12

• Tachycardia
• Skin flushed, hot, dry
• Mydriasis
• Agitated delirium
• Urinary retention
• Red as a beet, hot as a hare, mad as a hatter , dry as a bone
• Ex: Jimson weed, diphenhydramine

Question 13

clinical effects of Sympatholytics (objective, but he didn’t stress to know this)

Answer 13

– Hypotension 
– Bradycardia 
– Miosis 
– Decreased peristalsis
– Ex: Beta blockers Clonidine

Question 14

clinical effects of Cholinergics (objective, but he didn’t stress to know this)

Answer 14

– Diarrhea 
– Urination 
– Miosis 
– Bronchospasm 
– Emesis 
– Lacrimation 
– Salivation
– Ex: Organophosphate insecticides, Nerve agents

Question 15

clinical effects of Serotonin (objective, but he didn’t stress to know this)

Answer 15

– Tachycardic, tremor
– Left side of body with spasms esp jaw
– Hallucinations, garbled speech

Question 16

clinical effects of Opiates (objective, but he didn’t stress to know this)

Answer 16

– Miosis
– Coma
– Resp depression
– Hypotension