A 55-year-old woman comes to the emergency department (ED) for evaluation of recurrent left
flank pain and vomiting. She has a history of recurrent
nephrolithiasis and recently noticed gross blood in her urine. Medical history is notable for obesity,
hypertension,
hyperlipidemia,
depression, and
type II diabetes mellitus. The patient has been taking
ondansetron at home for nausea as well as
losartan,
metformin,
rosuvastatin, and
sertraline for her other medical conditions. On physical exam, the patient has left
costovertebral angle tenderness. Blood is detected on
urinalysis. The patient's symptoms are well controlled during the ED visit, and she is subsequently discharged with prescription analgesia, additional
antiemetics, and urology follow-up. Three days later, the patient is brought back to the ED altered,
diaphoretic, and agitated. Temperature is 39.4°C (103°F),
pulse is 122/min, respirations are 20/min, and
blood pressure is 184/95 mmHg. She has bilateral
mydriasis and
myoclonus. Which of the following medications was the most likely precipitant of this patient's clinical presentation?
