Supplementary Table. Discharge summaries for 12 hypothetical patients
Case
Category
number
1
Nontoxicological
(Epileptic
seizure)
2
3
4
Clinical summary as presented in questionnaire
Female, Date of birth 20 Mar 1989, Admitted 20 Apr 2010, Discharged 20 Apr 2010
Presenting complaint: Seizure
Principal diagnosis: Epileptic seizure
Active problems: Epilepsy
Past medical history: Mild asthma
Allergies: None known
Medication on discharge: Sodium valproate 800mg twice daily, Salbutamol inhaler 2 puffs
when required
Clinical summary: Admitted after experiencing two seizures within an hour. She has had
epilepsy for 2 years but has not had a seizure for 3 months. She had been taking her
sodium valproate regularly. On examination she was initially drowsy and confused but
recovered over several hours. She was afebrile and there were no focal neurological
signs. Bloods (FBC, electrolytes and CRP) were normal. She was observed for 8 hours
and had no further seizures in hospital. Her sodium valproate dose was increased from
600mg to 800mg bd on neurology advice, and she will be reviewed in clinic.
Follow up: Dr Green’s neurology clinic in 2 month
Female, Date of birth 20 Apr 1990, Admitted 20 Apr 2010, Discharged 20 Apr 2010
Nontoxicological Presenting complaint: Palpitations
Principal diagnosis: Supraventricular tachycardia
(SupraActive problems: Recurrent palpitations
ventricular
Allergies: None known
tachycardia)
Medication on discharge: None
Clinical summary: Presented with tachycardia and chest tightness. She had experienced
several previous milder episodes which resolved spontaneously. On examination she
had a pulse of 200/min regular but no signs of cardiac failure. ECG showed a narrowcomplex tachycardia with no visible P waves. Attempts to terminate the tachycardia by
Valsalva manoeuvres and carotid massage were unsuccessful, so she was given
adenosine 6mg then 12mg. She reverted to sinus rhythm and was stable after several
hours’ observation on the medical unit. Her ECG after the event was normal. She has
been referred to cardiology as an outpatient for consideration of electrophysiological
studies.
Follow up: Referred to cardiology (electrophysiology – Dr Edward)
Toxicological Male, Date of birth 10 Jan 1960, Admitted 20 Apr 2010, Discharged 21 Apr 2010
(Unconscious Presenting complaint: Unconscious
Principal diagnosis: Methadone and heroin overdose
due to
methadone and Active problems: Intravenous drug user, Cocaine and heroin user, Lives in hostel
Past medical history: Groin abscess, Hepatitis B
heroin
Allergies: Penicillin – rash
overdose)
Medication on discharge: Methadone 30 mg daily (daily observed consumption by
community pharmacist)
Clinical summary: Admitted after being found lying in the street unconscious. His initial
GCS was 6/15 when found by the ambulance crew, and was restored to 14/15 with
naloxone. He stated that he had injected heroin that morning as well as taking his
regular methadone from the chemist. He was observed on the ward until his GCS
recovered, then he self-discharged.
Follow up: Referred back to his community drugs unit
Recreational Female, Date of birth 12 Oct 1993, Admitted 20 Apr 2010, Discharged 20 Apr 2010
drug with no Presenting complaint: Palpitations
ICD-10 code Principal diagnosis: Mephedrone toxicity
(mephedrone) Allergies: None known
Medication on discharge: None
Clinical summary: Admitted feeling unwell after going to a nightclub. She ingested a
small amount of mephedrone, bought for her by a friend, and drank 2 shots of vodka.
She experienced palpitations and severe anxiety about 2 hours after taking the
mephedrone. On examination she was tachycardic (110/min) but had normal tone and
no nystagmus or clonus. Bloods were normal and ECG showed sinus tachycardia. She
stayed in the observation ward until the morning, when her symptoms had resolved.
Follow up: None
Case
Category
number
5
Recreational
drug with no
ICD-10 code
(gammabutyrolactone)
6
7
8
Clinical summary as presented in questionnaire
Male, Date of birth 5 Jun 1978, Admitted 20 Apr 2010, Discharged 29 Apr 2010
Presenting complaint: Collapse
Principal diagnosis: GBL toxicity, GBL withdrawal
Active problems: GBL dependence
Past medical history: Appendicectomy aged 8
Surgery and other procedures: ITU admission, intubation and ventilation
Allergies: None known
Medication on discharge: None
Clinical summary: Admitted after being found collapsed in a sauna, with initial GCS 5/15.
He was intubated and admitted to ITU, but quickly recovered consciousness and selfextubated himself. However he became very agitated and was thought to be
experiencing GBL withdrawal, as he had recently been using it every 2 hours. He was
treated with chlordiazepoxide for withdrawal and required a very high dose (total
350mg) in the first 24 hours. He was discharged after completing a reducing regimen of
chlordiazepoxide.
He was previously attending Dr Bateman's addiction clinic, and he has been referred back
to him.
Follow up: Referred to addiction clinic
Toxicological Male, Date of birth 5 Jun 1958, Admitted 20 Apr 2010, Discharged 21 Apr 2010
(Collapse due toPresenting complaint: Collapse
Principal diagnosis: Alcohol intoxication
alcohol
intoxication) Active problems: Alcoholic liver disease, Lives in hostel
Allergies: None known
Medication on discharge: Thiamine 100mg three times daily, Vitamin B complex strong 1
tablets daily
Clinical summary: Friends brought him to A&E after finding him lying in the floor of his
hostel room surrounded by empty cider bottles. On examination he smelt strongly of
alcohol but there was no focal neurological deficit or sign of head injury. He was given
IV fluids and Pabrinex. He sobered up while in the department and wanted to leave
because he needed a drink. He declined an offer to refer him to community alcohol
services.
Follow up: None
Toxicological Male: Date of birth 4 Sep 1970, Admitted 20 Apr 2010, Discharged 23 Apr 2010
(Body stuffer Presenting complaint: Body stuffer
with suspected Principal diagnosis: Body stuffer
opioid toxicity) Active problems: Hypertension
Allergies: None known
Medication on discharge: Bendroflumethiazide 2.5mg daily
Clinical summary: Brought in by police after collapsing in supermarket after being
arrested. He was witnessed to place 2 small plastic bags in his mouth immediately prior
to being apprehended, and he collapsed a few minutes later. The ambulance crew found
him semi-comatose with GCS 9/15, but he recovered to 15/15 after a single injection of
IM naloxone and they retrieved a torn piece of plastic from his mouth. We suspect that
the plastic bags contained heroin given his response to naloxone. However, he denied
ever taking illicit drugs or having swallowed any packets. Bloods and chest X-ray were
normal, but his initial abdominal X-ray showed a shadow in the stomach which may
have represented an ingested packet. This was not present on a subsequent film. The
patient refused to take activated charcoal or laxatives. He was observed for 48 hours
and did not develop any signs of toxicity, so he was discharged back to police custody.
Follow up: None
Toxicological Male, Date of birth 15 Nov 1982, Admitted 20 Apr 2010, Discharged 21 Apr 2010
(Chest pain and Presenting complaint: Chest pain
Principal diagnosis: Chest pain
tachycardia
after first use of Allergies: None known
Clinical summary: Admitted with 1 hour history of tight central chest pain, palpitations
cocaine)
and shortness of breath after snorting cocaine for the first time. Blood pressure 186/110
initially, settled to 146/90. ECG showed sinus tachycardia. He was treated with
diazepam and intravenous GTN. Troponin was negative 12 hours after the onset of
pain. He was monitored overnight and his symptoms resolved. He has been counselled
on the danger of cocaine use.
Follow up: None
Case
Category
number
9
Nontoxicological
(Chest pain,
probable
unstable
angina)
10
11
12
Clinical summary as presented in questionnaire
Male, Date of birth 14 Sep 1956, Admitted 20 Apr 2010, Discharged 21 Apr 2010
Presenting complaint: Chest pain
Principal diagnosis: Chest pain
Allergies: None known
Medication on discharge: GTN spray when required, Aspirin 75mg daily, Simvastatin
40mg every night
Clinical summary: Admitted with 1 hour history of tight central chest pain, occurring after
eating. Pain resolved in A&E. Normal ECG and CXR. He was kept in hospital for
observation and 12 hour troponin, which was negative. The chest pain might be cardiac
in origin so he has been started on aspirin and a statin pending an outpatient exercise
test. He will be seen in cardiology clinic after this.
Follow up: Cardiology clinic
Recreational Male, Date of birth 12 Oct 1991, Admitted 20 Apr 2010, Discharged 21 Apr 2010
drug with no Presenting complaint: Convulsion
ICD-10 code Principal diagnosis: Ecstasy toxicity
Allergies: None known
(ecstacy)
Clinical summary: Admitted after a witnessed convulsion outside a local nightclub. Had
taken 3-4 ecstasy tablets in the few hours prior to this. On arrival in ED was agitated
with HR 120, BP 140/100. Admitted overnight for observation and her symptoms
settled and she had no further convulsions. This was her first convulsion and as it was
temporally related to the use of ecstasy she will not need further investigation. She was
counselled regarding the risks of ecstasy and other drug use.
Follow up: None
Recreational Female, Date of birth 9 May 1987, Admitted 20 Apr 2010, Discharged 21 Apr 2010
drug with no Presenting complaint: Benzylpiperazine toxicity
ICD-10 code Principal diagnosis: Benzylpiperazine toxicity
Allergies: None known
(benzylClinical summary: Brought to the ED by a friend as she was ‘behaving strangely’ after use
piperazine)
of benzylpiperazine at a party. On arrival was mildly agitated but had no other features
of sympathomimetic drug toxicity. She was admitted overnight for observation and
treated with a single dose of oral lorazepam. Her symptoms had settled by the time of
discharge and we discussed were her issues relating to the use of recreational drugs.
Follow up: None
Toxicological Female, Date of birth 20 Apr 1989, Admitted 20 Apr 2010, Discharged 21 Apr 2010
(Chest pain and Presenting complaint: Chest pain
tachycardia in Principal diagnosis: Cocaine-related chest pain
regular user of Allergies: None known
Medication on discharge: None
cocaine)
Clinical summary: Presented with central chest pain 3 hours after insufflation of 2 lines of
cocaine at her 21st birthday party. On arrival in ED had sympathomimetic features
with HR 130, BP 184/116. Her chest pain and sympathomimetic features settled with
15mg diazepam. ECG showed no ischaemic changes and her troponin T was negative.
We discussed the risks associated with cocaine use. The patient has had multiple
episodes of cocaine related chest pain and some shortness of breath on exertion and so
will be investigated as an outpatient with an exercise test and echo and we will see her
in our clinic in 8 weeks time with the results of these.
Follow up: Exercise test and echo (booked), Outpatient follow up with Dr Brown in 8
weeks