What is the most likely cause of altered mental status, hyperthermia, tachycardia, and mydriasis in a 16-year-old male with a history of major depressive disorder, taking fluoxetine (selective serotonin reuptake inhibitor), and suspected ingestion of unknown substances?

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Differential Diagnosis

  • Single most likely diagnosis
    • Anticholinergic toxicity (e.g., due to diphenhydramine or other anticholinergic substances): The patient's symptoms, such as sleepiness, hot and dry skin, dry mucous membranes, decreased bowel sounds, and dilated pupils, are consistent with anticholinergic toxicity. The presence of unlabeled pills at the party and the patient's altered mental status support this diagnosis.
  • Other Likely diagnoses
    • Serotonin syndrome: Given the patient's recent initiation of fluoxetine, a selective serotonin reuptake inhibitor (SSRI), and the potential for other substances to interact with it, serotonin syndrome is a possible diagnosis. Symptoms such as altered mental status, tachycardia, and hyperthermia are consistent with this condition.
    • Alcohol or cannabis withdrawal: Although less likely, the patient's history of occasional alcohol and cannabis use raises the possibility of withdrawal, which could contribute to his altered mental status and autonomic instability.
  • Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
    • Opioid overdose: Despite the lack of specific symptoms suggestive of opioid use, the presence of unlabeled pills and the patient's altered mental status necessitate consideration of opioid overdose, which can be fatal if not promptly treated.
    • Aspirin or acetaminophen toxicity: Although less likely given the clinical presentation, the potential for severe consequences if missed (e.g., liver failure in acetaminophen overdose or severe metabolic acidosis in aspirin overdose) warrants consideration of these diagnoses.
  • Rare diagnoses
    • Neuroleptic malignant syndrome (NMS): Although rare, NMS can occur in patients taking certain medications, including SSRIs like fluoxetine. The patient's symptoms, such as altered mental status, hyperthermia, and autonomic instability, could be consistent with NMS.
    • Infectious or inflammatory causes: Less likely given the context, but potential infectious or inflammatory causes (e.g., meningitis, encephalitis) should be considered, especially if the patient's condition worsens or does not respond to treatment for the suspected toxic or metabolic cause.

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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