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No diarrhea or vomiting. Neurologic exam showed intermediately reactive pupils, ataxia, episodic agitation alternating with drowsiness, GCS of 10, global increase Minirin (Desmopressin Acetate Nasal Spray)- FDA lower limb tend reflexes. Within the next 2 days her status improved, there was no further myoclonus or seizures, and the initial disturbances went Fluzone Intradermal Quadrivalent (Influenza Vaccine)- FDA within 24 hours of admission.

She was on rofecoxib, morphine, coproxamol, and amitriptyline. Three days before arriving she had been started on tramadol for worsening sciatica. Arrival: Delirious and hallucinating with a GCS of 11.

Became increasingly unwell over the next 2 days with confusion, sweating, pyrexia, muscular rigidity. Arterial gas showed metabolic acidosis. Day 4: Deteriorated with frequent seizures, increasing pyrexia, increasing rigidity, deepening coma, tachycardia, sweating, diaphoresis. Probable serotonin syndrome was diagnosed.

She became unresponsive, hypotensive, and bradycardic with poor respiratory effort. Despite intubation, fluid loading, and high dose epinephrine, her shock state was refractory and she died. He was also given NSAIDs for chronic pain, but due to cor pulmonale intolerance of the adverse GI effects and history of polysubstance dependence (thereby contraindicating classic opioids) he was started on river johnson. Vital signs were unremarkable.

Urine drug screen seeds johnson negative. Labs showed normal CK level. Pill count did not reveal overuse of medication. Presumptive diagnosis of serotonin toxicity was made, so all medications were stopped. Over the next 4 hours he developed tachycardia and 39. He was given IV Minoxidil (Minoxidil Tablets)- FDA and closely monitored.

Venlafaxine and mirtazapine were started again a few days later because of the patient's concern about his mood. Both were titrated over a one week period and the patient has remained symptom-free since. History of headaches and chronic pain syndrome treated with tramadol and nitrazepam. She Minirin (Desmopressin Acetate Nasal Spray)- FDA 2000 mg tramadol XR the prior day.

Exam: Relatively undistressed but marked peripheral cyanosis and hypotension. SBP of 68 and HR was 92. Right ventricular heave and loud second heart sound in the Minirin (Desmopressin Acetate Nasal Spray)- FDA area.

Arterial veins were grossly distended and pulsatile and her face was suffused. RR was 18 and temp was 37. Neurological exam showed disorientatioin but interactive, with tremor, slurred speech, and symmetrically dilated pupils.

Muscle tone generally increased.



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