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1/14 #MedTwitter: The ED pages you for an admission: a 24-year-old male with a history of IVDU presenting with fever. How do you take his drug history?
2/14 As a resident, I fell into A + B, until @cuttingforstone taught me you need to know a lot more to appropriately Dx and Tx your patient. My mnemonic?
๐๐ฅ๐จ๐: Drug, Route, User, Goods.
๐๐ฅ๐จ๐: Drug, Route, User, Goods.
3/14 Buckle up for a deep dive into why a detailed drug history matters!
4/14 Know the specific ๐rug. Is it crack or cocaine? Black tar, white or brown powder heroin? Different drugs carry different risks:
Wound botulism & tetanus risk
much higher w/ black tar.
Wound botulism & tetanus risk
much higher w/ black tar.
5/14 Crack cocaine crack lung alveolar macrophage function impaired increased risk for lung infections including smear-positive TB. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2603115/
crack lung alveolar macrophage function impaired increased risk for lung infections including smear-positive TB. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2603115/
6/14 Learn the ๐ฅoute and where: is it IV vs. IM vs. IN vs. SQ vs. INH vs. PO vs. PR? ๐๐๐๐ ๐ฎ๐ ๐๐ผ๐ ๐๐ผ๐๐น๐ฑ ๐ณ๐ผ๐ฟ ๐ฎ๐ป๐ ๐บ๐ฒ๐ฑ๐ถ๐ฐ๐ฎ๐๐ถ๐ผ๐ป ๐ต๐
. Why?
7/14 Pneumomediastinum and PTX is a known complication from INH crack cocaine: deep inhalation + repeated Valsalva or cough increased intrathoracic pressure barotrauma.
You should examine all sites of injection for potential infection.
increased intrathoracic pressure barotrauma. You should examine all sites of injection for potential infection.
8/14 Who is your ๐จser? Who do they use with and how do they obtain the drugs? @CardiBeatMD reminded me to ask about other high-risk behaviors (ie. needle sharing, exchange sex for drugs). Learn and understand your patientโs risk environment.
9/14 ๐oods matter: paraphernalia. Letโs take the example of IV heroin: it needs to be dissolved (whereโs their water source, is it sterile), drawn up in a needle (sterile needles? if not, how do they clean it? Any saliva contamination putting them at risk for anaerobic infx?)
10/14 Most users will draw up the dissolved drug through a filter to remove impurities. Filters can be cigarette filter or cotton balls.
Ever heard of ๐ค๐ฐ๐ต๐ต๐ฐ๐ฏ ๐ง๐ฆ๐ท๐ฆ๐ณ?
Ever heard of ๐ค๐ฐ๐ต๐ต๐ฐ๐ฏ ๐ง๐ฆ๐ท๐ฆ๐ณ?
11/14 Cotton fever is related to boiling up used filters to extract residual drug. ๐๐ฏ๐ต๐ฆ๐ณ๐ฐ๐ฃ๐ข๐ค๐ต๐ฆ๐ณ ๐ข๐จ๐จ๐ญ๐ฐ๐ฎ๐ฆ๐ณ๐ข๐ฏ๐ด colonizes the cotton plant and produces an endotoxin, which may explain the fevers.
12/14 A diagnosis of exclusion, but cotton fever presents as fever + leukocytosis with negative blood cultures, and usually sets in 30 mins after injection. The syndrome is self-limited and resolves within 24 hours. https://pubmed.ncbi.nlm.nih.gov/2362114/
13/14 Finally, patients who use drugs (PWUD) experience discrimination in healthcare environments. Stigma is a barrier to seeking tx & associates w/ higher-risk behaviors. We cannot get our patients better until we can see ourselves in them, and treat them as we would our own kin
14/14 ๐ง๐ฎ๐ธ๐ฒ๐ฎ๐๐ฎ๐๐:
1. Learn about your patientโs drug history non-judgmentally as you would learn any other medication history.
2. Remember DRUG: the specific Drug, Route, User, Goods.
1. Learn about your patientโs drug history non-judgmentally as you would learn any other medication history.
2. Remember DRUG: the specific Drug, Route, User, Goods.
What else am I missing? #MedTwitter #MedStudentTwitter #Inclusion #MedEd @Sharminzi @StanfordChiefs @DxRxEdu @sargsyanz
