ETOH Flashcards
Which one of the following occurs with delirium tremens but is not usually seen with less severe forms of alcohol withdrawal? (check one)
Fever
Hypertension
Tachycardia
Seizure
Visual hallucinations
Fever
Chronic excessive alcohol intake produces functional changes in neurotransmitter activity that can lead to a net increase in excitatory neuroreceptor activity when the person stops drinking. Withdrawal can be divided into four levels of severity: minor, major, seizures, and delirium tremens. Minor alcohol withdrawal is characterized by tremor, anxiety, nausea, vomiting, and/or insomnia 6–24 hours after the patient’s last drink. Major withdrawal occurs 10–72 hours after the last drink and can include the signs and symptoms of minor withdrawal, as well as visual and auditory hallucinations, diaphoresis, tachycardia, and elevated blood pressure. Alcoholic seizure generally occurs within 2 days of the last drink and may be the only sign of withdrawal, although approximately one-third of these patients will progress to delirium tremens. The onset of delirium tremens can occur anytime within 3–10 days following the last drink. The defining clinical finding is delirium, but the findings seen in milder forms of alcohol withdrawal can also be present, and may be more severe. Fever is most often seen with delirium tremens and is less common with less severe forms of alcohol withdrawal.
A 47-year-old female sees you for a health maintenance visit. During the course of your discussion she discloses a long history of significant alcohol intake that has impaired her work and personal life, meeting criteria for moderate to severe alcohol use disorder. She began working with a therapist to address this issue several months ago and reports that her last drink was 26 days ago. Her health is otherwise good and laboratory studies reveal normal liver and renal function.
Which one of the following medications would help reduce the risk of relapse? (check one)
Buspirone
Duloxetine (Cymbalta)
Fluoxetine (Prozac)
Naltrexone
Quetiapine (Seroquel)
Naltrexone
Alcohol use disorder (AUD) is common in the United States but remains undertreated, especially with pharmacotherapy. FDA-approved therapies include naltrexone, acamprosate, and disulfiram. Non–FDA-approved therapies with evidence of benefit include baclofen and topiramate. AUD commonly coexists with other psychiatric conditions and in these situations treating those comorbid conditions is critical. For patients with coexisting depression or anxiety, buspirone, duloxetine, or fluoxetine could be considered in addition to one of the other medications listed to address AUD. Quetiapine, which is an antipsychotic, has no role in the treatment of AUD.
A 35-year-old male has a negative past medical history and a normal physical examination. He reports that he smokes half a pack of cigarettes per day and has 3–4 beers per week. A comprehensive metabolic panel reveals an ALT (SGPT) of 30 U/L (N 10–40) and an AST (SGOT) of 84 U/L (N 10–30). The remaining laboratory studies are negative. There is no family history of liver disease.
The laboratory findings suggest which one of the following? (check one)
Hepatitis C
Hemochromatosis
Gilbert syndrome
Alcoholic liver disease
Nonalcoholic liver disease
Alcoholic liver disease
An AST (SGOT) to ALT (SGPT) ratio greater than 2:1 suggests alcoholic liver disease, and a ratio of 3:1 or higher is highly suggestive of alcoholic liver disease. With most hepatocellular disorders, including nonalcoholic fatty liver disease, viral hepatitis, and iron overload disorder, the patient will have an AST to ALT ratio <1.
A 42-year-old male with alcohol use disorder tells you that his last drink was 7 days ago and asks if there are any medications available to help him maintain abstinence from alcohol. He has no other medical or psychological problems.
Which one of the following pharmacologic agents could help reduce this patient’s alcohol consumption and increase abstinence? (check one)
Acamprosate
Amitriptyline
Paroxetine (Paxil)
Promethazine
Venlafaxine (Effexor XR)
Acamprosate
For this patient, acamprosate is the most effective medication to help maintain alcohol abstinence. Antidepressants may be beneficial in patients with coexisting depression. The antiemetic ondansetron may also help decrease alcohol consumption in patients with alcohol use disorder.
A 65-year-old male with type 2 diabetes mellitus, hypertension, and obstructive sleep apnea sees you for follow-up. He does not use tobacco or other drugs, and his alcohol consumption consists of two drinks per day. His BMI is 31 kg/m2, and he just started a fitness program. The patient tells you that his brother was recently diagnosed with atrial fibrillation and he asks you if this increases his own risk.
Which one of the following factors would increase the risk of atrial fibrillation in this patient? (check one)
Alcohol use
Treatment with lisinopril (Prinivil, Zestril)
Treatment with pioglitazone (Actos)
Use of a continuous positive airway pressure (CPAP) device
Physical stress
Alcohol use
Alcohol consumption greater than one drink/day has been associated with atrial fibrillation. While not recommended to prevent atrial fibrillation, pioglitazone and lisinopril have both been associated with lower rates of atrial fibrillation compared to alternative therapies. Treatment of obstructive sleep apnea, along with a regular fitness regimen, has been associated with a decrease in the recurrence of atrial fibrillation.
A 65-year-old male presents to your office with tremor, difficulty sleeping, nausea, agitation, and transient visual hallucinations 3 days after he stopped drinking alcohol following a 3-day binge. His wife has noted increasing confusion over the past several hours.
Which one of the following medications would be best for treatment of his alcohol withdrawal delirium? (check one)
Carbamazepine (Tegretol)
Haloperidol
Lorazepam (Ativan)
Phenobarbital
Propofol (Diprivan)
Lorazepam (Ativan)
A patient with alcohol withdrawal delirium (delirium tremens) is best treated as an inpatient, usually in an intensive-care unit. Evaluation of these patients consists of a workup to identify comorbid medical conditions, and treatment includes supportive care, intravenous thiamine, and medications to control agitation, promote sleep, and raise the seizure threshold. The first-line pharmacologic agent for the treatment of alcohol withdrawal delirium is a benzodiazepine, such as lorazepam. The other medications listed are used as adjunctive treatment for severe symptoms or for patients who do not have an adequate response to high doses of benzodiazepines. They all may have significant side effects and offer few advantages for most patients compared to benzodiazepines.
While you are volunteering at a shelter for victims of domestic violence, a mother asks you to examine her 12-year-old daughter who has an earache. During the examination you learn that the child grew up in a household where there was substance abuse, mental illness, and violent treatment of her mother. You are told that the child’s father is now incarcerated.
Considering how adverse childhood experiences affect behavior and health, this child is at greatest risk for which one of the following? (check one)
Alcoholism
Attention-deficit disorder
Borderline personality disorder
Dissociative disorder
Schizophrenia
Alcoholism
Family physicians should know about health risks associated with adverse childhood experiences (ACEs). Many risk factors are associated with cumulative ACEs. As ACEs increase so do the risks for alcoholism, drug abuse, depression, suicide attempts, smoking, poor self-rated health, ≥50 sex partners, sexually transmitted disease, physical inactivity, severe obesity, and several chronic medical conditions that are leading causes of death in adults. Of the options listed, this child is at greatest risk for alcoholism.
A 4-year-old male is brought to your office by his adoptive parents who are concerned about his poor behavior and intellectual development. The patient is in the 7th percentile for height and weight. There have been some indications of alcohol abuse by his biological mother.
Which one of the following facial dysmorphologies would be most consistent with a diagnosis of fetal alcohol syndrome? (check one)
A central chin “dimple”
Low-set ears
A smooth philtrum
A widened vermilion border of the lower lip
Elongated palpebral fissures
A smooth philtrum
The classic facial dysmorphologies associated with fetal alcohol syndrome are a smooth philtrum,
shortened palpebral fissures, and a thin vermilion border of the upper lip. Two out of these three
characteristics are required for the diagnosis of fetal alcohol syndrome. Low-set ears and a central chin
dimple are not associated findings.
A 38-year-old female presents for follow-up of a second hospitalization in the past 3 months for acute hepatitis, thrombocytopenia, and alcohol withdrawal symptoms treated with benzodiazepines. She says that prior to her hospitalization a week ago she had been drinking a half pint of vodka daily. She reports that her drinking has gradually increased over the past 10 years but increased significantly 6 months ago after she lost her job at a bar and grill. She knows her alcohol consumption is causing damage to her liver and tells you that her aunt died of alcoholic cirrhosis this year. Despite this knowledge she does not want to stop drinking at this time. She has looked into several alcohol cessation programs in the area but does not think that they are a good fit for her.
She currently lives with her boyfriend who also uses alcohol and cocaine regularly. She is not currently speaking to her mother because they “don’t see eye to eye.” She tells you that she has not consumed alcohol since her discharge from the hospital 2 days ago. She reports that her abdominal pain, nausea, and vomiting have resolved and she is feeling well.
The most likely diagnosis is (check one)
alcohol intoxication
alcohol withdrawal
alcohol use disorder in early remission
severe alcohol use disorder
severe alcohol use disorder
This patient presents with 6 out of 11 symptoms of alcohol use disorder within a 12-month period,
including a strong desire or urge to use alcohol, recurrent alcohol use that has contributed to the inability
to fulfill work obligations, continued alcohol use despite interpersonal problems with her family, continued
alcohol use despite knowledge that it is causing physical damage to her liver, development of a tolerance
to the effects of alcohol over time, and withdrawal symptoms that require treatment with benzodiazepines.
Mild alcohol use disorder is defined by the presence of 2–3 of the 11 symptoms documented in the DSM-5,
whereas 3–5 symptoms indicate moderate alcohol use disorder and 6 or more symptoms indicate severe
alcohol use disorder. This patient has severe alcohol use disorder that is currently active. Early remission
is defined as the absence of symptoms for at least 3 months but less than 12 months. She is not currently
intoxicated, and she does not currently have withdrawal symptoms related to her alcohol use over a week
ago.
