A 16-year-old boy is brought to the emergency department by his friends for severe anxiety. He became paranoid and unusually withdrawn at a party and began rocking back and forth, saying, "I feel like I can't breathe" and "I'm afraid I'm going to die." Prior to the party, he was his regular "happy and outgoing" self. The patient has intermittent back pain from a bicycle accident last year for which he takes oxycodone as needed. Temperature is 36.1 C (97 F), blood pressure is 140/80 mm Hg, pulse is 110/min, and respirations are 18/min. Pulse oximetry is 98% on room air. Examination shows an anxious and withdrawn boy with 3-mm pupils, conjunctival injection, dry oral mucosa, and a healed scar on his right thigh from his bicycle accident. Which of the following is most consistent with this patient's presentation?

Question

A 16-year-old boy is brought to the emergency department by his friends for severe anxiety.  He became paranoid and unusually withdrawn at a party and began rocking back and forth, saying, "I feel like I can't breathe" and "I'm afraid I'm going to die."  Prior to the party, he was his regular "happy and outgoing" self.  The patient has intermittent back pain from a bicycle accident last year for which he takes oxycodone as needed.  Temperature is 36.1 C (97 F), blood pressure is 140/80 mm Hg, pulse is 110/min, and respirations are 18/min.  Pulse oximetry is 98% on room air.  Examination shows an anxious and withdrawn boy with 3-mm pupils, conjunctival injection, dry oral mucosa, and a healed scar on his right thigh from his bicycle accident.  Which of the following is most consistent with this patient's presentation?

Quizplus · Accepted Answer

11ec25c8_d769_bafb_bc81_0520e90a139c_MD0003_00 This patient's presentation is most consistent with cannabis (marijuana) intoxication. The primary psychoactive chemical in cannabis is delta-9-tetrahydrocannabinol (THC), which can produce effects within minutes if inhaled or after a few hours if ingested. With the advent of high-potency cannabis formulations (eg, edibles, concentrates), unintentional ingestion of high doses of THC is becoming more common. Physiologic effects include conjunctival injection (red eyes), dry mouth, tachycardia, and increased appetite. Cognitive effects include slow reaction time, incoordination, impaired short-term memory, and poor concentration. Some individuals may experience dysphoria, social withdrawal, anxiety, and paranoia when exposed to higher doses of THC. Psychomotor impairment lasts beyond the timeframe of euphoria and can persist for up to a day. (Choice A) Bath salts (synthetic amphetamine analogues) intoxication presents with tachycardia, hypertension, mydriasis, agitation, and violent behavior at higher doses. (Choice C) Cocaine intoxication can also cause anxiety, paranoia, and tachycardia, but it is associated with pupillary dilation, not conjunctival injection, as well as diaphoresis. (Choice D) Cocaine withdrawal typically presents with dysphoria, difficulty concentrating, and increased sleep and appetite, as well as depression and possible suicidality. It does not cause the dry mouth and conjunctival injection seen with cannabis use. (Choice E) Lysergic acid diethylamide (LSD) intoxication presents with tachycardia, hypertension, visual hallucinations, and paranoia at higher doses. (Choice F) Opioid intoxication is characterized by the triad of respiratory depression, pinpoint pupils, and central nervous system depression. Other features include hypotension, hypothermia, and bradycardia, none of which are seen in this patient. (Choice G) Opioid withdrawal is characterized by lacrimation, pupillary dilation, yawning, diaphoresis, and gastrointestinal symptoms (eg, nausea, vomiting, diarrhea). (Choice H) Phencyclidine intoxication typically presents with nystagmus and ataxia. Although patients may experience psychosis, they usually have associated violent behavior, agitation, and dissociation. Educational objective: Patients with cannabis intoxication typically present with conjunctival injection, dry mouth, tachycardia, and increased appetite. Psychomotor impairment, anxiety, and paranoia may also occur, especially at higher doses. References: The effects of cannabis intoxication on motor vehicle collision revisited and revised. (http://www.ncbi.nlm.nih.gov/pubmed/26878835) Psychiatric and medical management of marijuana intoxication in the emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/25987916)

A 16-Year-Old Boy Is Brought to the Emergency Department by His