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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
https://abs.twimg.com/emoji/v2/... draggable="false" alt="โก๏ธ" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts"> much higher w/ black tar.
Wound botulism & tetanus risk
5/14 Crack cocaine https://abs.twimg.com/emoji/v2/... draggable="false" alt="โก๏ธ" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts"> crack lung https://abs.twimg.com/emoji/v2/... draggable="false" alt="โก๏ธ" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts"> alveolar macrophage function impaired https://abs.twimg.com/emoji/v2/... draggable="false" alt="โก๏ธ" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts"> increased risk for lung infections including smear-positive TB. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2603115/">https://www.ncbi.nlm.nih.gov/pmc/artic...
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 https://abs.twimg.com/emoji/v2/... draggable="false" alt="โก๏ธ" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts"> increased intrathoracic pressure https://abs.twimg.com/emoji/v2/... draggable="false" alt="โก๏ธ" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts"> barotrauma.
You should examine all sites of injection for potential infection.
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/ ">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