COW – v1.1



You are working your first overnight shift at your new job right out of residency. Part of your contract is to cover a smaller satellite facility with limited resources that takes a steep dive at night.

The triage nurse rolls by your station with a young woman in a wheelchair. The nurse is moving with purpose, which makes you a little nervous. The patient is bent over and holding her abdomen. She holds an emesis basin on her lap.  It looks like there is a small amount of blood present.

She seems sleepy but arousable and is unable to give much of meaningful history.

The nurse gets her in bed and points to her gravid uterus. She grimaces and puts the patient on the monitor.

Her husband arrives. He says that she has been depressed and withdrawn recently, not sure why. She texted him an ambiguous farewell message a few hours ago. He hands you an empty bottle of prenatal vitamins.  He says that she just bought this a couple of days ago and is concerned that she took all of them.

ROS: Postive for abdominal pain and hematemesis, decreased mental status






? prenatal vitamins





Physical Examination:

P 110  BP 95/60  RR 12  T 36.5

Fetal heart tones are 135 bpm via bedside ultrasound

General: Young woman, lying in bed, fetal position, sleepy but arousable


Neck: supple, no LAD

Heart: Tachycardic, clear S1 and S2. No murmurs. No extra heart sounds

Lungs: clear

Abdomen: Gravid uterus, about 30 cm from pubic bone

Extremities: Thready pulses. No c/c/e

Neuro: Sleepy. Follows commands. MAE x 4. Normal reflexes at knees and ankles. No rigidity.


Na 138

K 3.4

Cl 108

HCO3 16

Glucose 168


Hgb 9.8

Hct 29

Plt 233K

VBG 7.28/25/152

QUESTION #1: You are concerned about overdose. What component of the prenatal vitamin is most concerning?

A. Vitamin A
B. Folinic acid
C. Calcium
D. Iron
E. ascorbic acid

QUESTION #2: Which is not an indication for deferroxamine?

A. 2 hour iron level >300
B. 4 hour iron level >500
C. Metabolic acidosis
D. Lethargy/AMS

QUESTION #3: What are potential adverse reactions of deferroxamine?

A. Discolored urine
B. Hypotension
D. Ototoxicity
E. A and B
F. B and C
G. All of the above

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