Approach to recreational substance exposure (pediatrics) Quiz: Ace Your Exams

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A 13-year-old boy is brought to the emergency department by ambulance for a syncopal episode that occurred while he was with friends. EMS reports that the patient's friends left the scene after calling for help, and the patient was found lying on the ground alone. Graffiti and empty spray paint cans were observed near the patient. The patient awakened when the team moved him to the ambulance, and he reported dizziness and a headache. Temperature is 37.0°C (98.6°F), pulse is 122/min, respiratory rate is 18/min, systolic blood pressure is 135/84 mmHg, and oxygen saturation is 98% on room air. On examination, the patient is slurring his speech. Crusted blood is noted in the right nares and a nasal ulcer is present. There is no obvious trauma to the head or neck. Neurologic exam reveals global hyporeflexia. Examination of the hands reveals traces of black paint. Routine urine drug screen is negative. Which of the following is most likely to identify the cause of this patient’s symptoms? 

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