Case Presentation: A 25 year-old man presented with agitation and altered mental status. He was placed in physical restraints and given Ativan due to severe agitation. He was found to be tachycardic, with dilated pupils, erythematous arms, and dry skin. Upon further questioning, the patient endorsed blurred vision, dry mouth, and difficulty urinating. A foley catheter was placed and he put out one liter of urine. Electrolytes, creatine kinase (CK), and TSH were within normal limits. CT head was unrevealing. UDS returned positive for PCP and a mass spectrometry positive for diphenhydramine and dextromethorphan. His acute psychosis resolved with time and abstinence from the drug for twenty-four hours. Once the patient was calm, he admitted to taking fifteen pills of cold medicine as a means to get high. With further investigation, it was found that dextromethorphan can cause a positive UDS for PCP.
Discussion: Risks involved with over-the-counter (OTC) medications and supplements can present a challenge to the hospitalist. In this case, the patient had easy access to dextromethorphan-chlorpheniramine pills that are commonly used for cold and flu symptoms, and can be purchased over-the-counter at any grocery store or pharmacy. This patient was acutely intoxicated and therefore altered due to ingestion of high doses of dextromethorphan. His acute psychosis resolved with time and abstinence from the drug. He also was experiencing anticholinergic toxicity symptoms due to the chlorpheniramine in the cold medication. It was important to recognize the anticholinergic effects in order to identify and treat the urinary retention to prevent kidney damage and other adverse consequences. OTC medications should be included on the differential for altered mental status and drowsiness in all patients as it is often under-recognized. Given the prevalence of OTC medication misuse and dependence, it is critical that hospitalists educate their patients on the short and long-term risks and safety of OTC medications as well as the risk for addiction and dependence.
Conclusions: Hospitalists are often prepared to recognized a wide variety of toxidromes include anticholinergic toxicity. Review of the medications with the patient that occurs at admission may reveal the source of toxicity. Reconciliation of these medications should include prescription and over-the-counter medications to ensure an accurate and timely diagnosis.