Emily Cartwright

HESI
7/17/2016
Case Study #3- Case 872
A. Patient Medical History:
Patient is a 31 year old male with an unknown medical history. Due to this, there is no
solid evidence the patient has any pre-existing problem or conditions. There is also no
evidence of hereditary problems.
B. The Complaint:
Patient was taken to the emergency department after police found him. He was found
naked, walking around a ditch off the freeway. He was unaware of what was going on,
and acting violently.
C. The Objective Assessment:
Patients vitals were 38.2 degrees celsius (100.76 degrees fahrenheit), which is higher
than the normal body temperature of 36 - 37 degrees celsius (96.7 - 98.5 degrees
fahrenheit). Patient had a heart rate of 112 beats per minute, higher than the average of
60-100 beats per minute (13). The blood pressure of the patient was 156/108 mmHg
(millimeters of mercury), much higher than the average of 120/80 mmHg (14). The top
number, called systolic, measures the pressure in the arteries when the heart beats, while
the bottom number, called diastolic, measures the pressure in the arteries between
heartbeats (14). The patients blood pressure shows signs of stage 2 hypertension (systolic
number being around 160 or higher and diastolic number being around 100 or higher)
(14). Different from prehypertension and stage 1 hypertension, stage 2 hypertension is a
higher systolic and diastolic range than prehypertension and stage 1 (C).
Physical examination of the patient shows diaphoresis (excessive sweating), mydriasis
(dilated pupils), dried blood in the nose, and marks on arms (punctures where needles
were injected). Patient had no focal neurological deficits (able to talk, move arms and
legs in a functional manner, see clearly, and hear).
Patient was given a cooling blanket to prevent hyperthermia (body temperature exceeding
the norm). Intravenous fluids (IVFs) were given in hope it would lower the patient's
blood pressure. Benzodiazepines were also given to help make the patient less aggressive.
Benzodiazepines affect the neurotransmitters in the brain, gamma-aminobutyric acid
(GABA) is the specific neurotransmitter benzodiazepines affect to help slow down nerve
activity, making the person more relaxed (16). After multiple doses, he was still showing
signs of aggression towards others, so he was sedated with propofol, which decreased
level of consciousness (15).
D. Analysis of Patient Symptoms and Lab Tests:
The patient's blood serum test values showed some signs of concern. The white blood cell
(WBC) count is high at 24.8x10^9/L (liter), when on average, it is 4-11x10^9/L (18).
WBC are in charge of fighting substances foreign to the body. The hemoglobin is low at

11.5 g/dL (grams/deciliter), while it should be 13.5-17.5 g/dL (18). Hemoglobin (Hgb)
attaches to red blood cells (RBCs) and help bind oxygen to the RBCs to then travel
throughout the body to places it is needed. Chloride (Cl) levels were high at 110 mEq/L
(milliequivalents/liter), when averages show between 96 and 106 mEq/L (6). Cl is an
electrolyte (minerals found naturally in the body), used in the body for to help maintain
blood pressure, body pH, and blood volume (2). Carbon dioxide (CO2) levels are low at
20 mEq/L, when the normal average is 23 to 29 mEq/L (1). Blood Urea Nitrogen (BUN)
levels are high at 28 mg/dL (milligrams/deciliter), while averages are 7-20 mg/dL (9).
Total protein (TProt) levels are low at 6 gm/dL (grams per deciliter), when they should be
around 6.0 to 8.3 gm/dL (5). Both aspartate transaminase (AST) and alanine transaminase
(ALT) were in high levels with AST being 229 U/L (units/liters) and ALT being 78 U/L
(10). Averages levels for AST are 10-40 units/L and ALT levels are 7-56 units/L (7). AST
and ALT are enzymes that help speed up chemical reactions going on in the body (7). The
patient's blood lactate levels were high at 3.1 mmol/L (millimole per liter), when on
average it is usually around .5-1 mmol/L (B). Creatine Phosphokinase (CPK) levels are
high at 207 U/L (units per liter), when it is usually at 22 to 198 U/L (A). CPK helps turn
one form of energy (adenosine triphosphate a.k.a. ATP) into other forms of energy
(phosphocreatine a.k.a. PCr and adenosine diphosphate ADP) (12).
The patient's urine test also showed some concerning values. Urine ketones levels show
2+, which is higher than the normal level of none at all (4). The amount of protein in the
urine is 100 mg/dL (milligrams/deciliter), lower than the average of 150 mg/dL (4).
WBC in the urine is high with 6 WBCs/hpf (white blood cells/ high-power field ), rather
than 2-5 WBCs/hpf (4). The RBC amount in the urine is high at 14 RBCs/hpf (red blood
cells/high-power field ), when the normal range is 2 RBCs/hpf (4). Hyaline casts (a type
of urine casts with a smooth texture) amount is higher than normal at 5 hyaline casts/lpf
(low-power field), when the normal is 0-4 hyaline casts/lpf (4).
The patients needle injections in the arm, dilated pupils, and UDS showing
benzodiazepines abuse evidence that the patient has recent substance abuse. No medical
history means there has been no evidence of the patient getting a vaccination or IV
recently. If there was, it would explain the needle punctures. But since there is no
evidence of this, the next plausible assumption is recent drug use. The dilation of pupils is
a main sign of recent drug use (20). The urine drug screening shows elevated volume of
benzodiazepines is also alarming.
The patient being naked, confused and acting aggressive once found by the police is a
key component in this case. Being naked in public, and confused how they got there
indicates that he could possibly have a mental illness or had consumed something to have
forgotten why he was in the ditch and had lost his clothes. Since the patient is either
mentally unstable, or had taken in something that made him unaware of himself and his
surroundings, it explains why he would be naked when found (19). Aggression is a
common side effect after coming down from a high of an addictive drug, so him saying
aggression towards others makes a lot of sense (8).

UDS (urine drug screening) was used to see if other substances have been used by this
patient. Benzodiazepines were the only thing that flagged as positive. This made
clinicians very suspicious of the patients toxicity levels.
Blood in the urine shows signs of internal bleeding. This could be due to kidney damage,
disease, or failure. Additionally high levels of white blood cells in the urine can mean
some sort of infection in the kidneys or bladder.
Patient has an escalated blood pressure, excessive sweating, bloody nose, and allusion to
kidney problems. All symptoms of cathinone poisoning and the intake of bath salts.
E. Diagnosis:
Diagnosis for this patient is cathinone poisoning (caused by a drug by the street name of
bath salts), and kidney disease. The drug can be taken in in a variety of different ways,
one being injecting it with a needle, which matches with the patient's needle injection
marks on the arms (19). Cathinone has been found to stimulate the release of dopamine (a
chemical released when someone is happy or has slept) (11). Cathinone poisoning
symptoms include, but are not excluded to, confusion, aggression, overheating, paranoia,
hypertension (stage 2), and kidney failure (8).
F. Treatment:
Rehab is to be assigned to the patient which typically is an eight to ten week program, on
average, that gives recovering addicts a chance to rebuild (8). Other treatments are to do
further tests on the kidneys to see full damage done. This will allow for the correct
diagnostic treatment of the internal bleeding.
G. Prognosis and Treatment Plan:
The severity of the addiction to the drug, the harder it is to detoxify, and the worse the
withdrawal symptoms (20). Withdraw symptoms can be craving of drug, depression,
anxiety, irritability, inability to concentrate, memory loss, fatigue, violent actions, and
poor quality of sleep (20). Recovery time for each patient is different, and the severity of
the addition plays a key role in that.

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