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NBME 21 Answers

nbme21/Block 4/Question#7

A 14-year-old boy is brought to the physician by ...

Inhaled glue

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 +12  upvote downvote
submitted by sweetmed(83),

Toluene, the main component of volatile glues, lacquer thinners and aerosol paints is the chemical responsible for most clinical toxicity. Inhalants cause an initial excitatory response through the release of epinephrine and activation of the dopamine system, followed by central nervous system depression mediated by the use of GABA pathway1 It manifests as a sense of euphoria, excitation, dizziness, disinhibited behaviour and exhilaration similar to alcohol intoxication, thus resulting in psychological dependence. Repeated inhalations by the user to prolong the intoxication will develop in headache, slurred speech, diplopia, gait abnormality, delusions, visual hallucinations and disorientation. Behavioural changes and characteristic odour on breath or clothing are helpful clues to detect cases. Suspected users may also complain of cough, stuffy nose, sneezing, flushing, salivation, nausea, vomiting and photophobia. Other signs and symptoms of inhalant abuse include spots or sores in or around the mouth, injected sclera, nystagmus, irritability or excitability, anxiety and sleep disturbances. Paint or other stains on the face, hands, or clothes are other indicators of abuse. Severe dryness of facial skin and mucus membranes can also be a feature of repeated, prolonged use of volatile substances8 . Bacterial infection of the dry and cracked skin may result in perioral and perinasal pyodermas, sometimes referred to as “huffer’s rash”9

 +5  upvote downvote
submitted by mcl(378),

Gait problems raises suspicion for alcohol abuse or inhaled glue. However, onset of gait problems is relatively rapid (couple of months) and gait disturbance with regards to alcohol is either due to intoxication or chronic abuse. Alternative explanation available on SDN. Also see toluene toxicity on medscape.

sbryant6  I got this correct solely based on the patients demographic. Glue is cheap and easily accessible to underage populations. +2  
whossayin  Kinda racist of us but that’s how I reasoned my answer too lol @sbryant6 +  
hpsbwz  how is it racist if the only thing thats given is his age lol @whossayin +10  

Inhaled glue is more likely than alcohol b/c of its ease of access for a minor and relative abuse potential in the age group.