UW MED psych drugs cases (Nr 9-13) - ALCOHOL Flashcards
(9) 35 y/o man is evaluated in the hospital for a tonic-clonic seizure 30 hours after he underwent right inguinal hernia repair. The operation was uneventful, but the patient gradually became restless afterward. Medical history is remarkable for gastritis and a 15-year history of tobacco and alcohol use. The patient lives alone. Medications include omeprazole and morphine for pain control. Temp. 37.7 C, BP 155/94, pulse 114/min, RR 18/min. The patient is not oriented to place or time. He appears diaphoretic and agitated . Neurologic examination shows tremor of the upper and lower extremities; deep tendon reflexes are 3+ bilaterally. The lungs are clear to auscultation. The incision site is dry, intact, and healing well with no evidence of infection. Na 137; K 3,5; Cl 101; Cr, BUN - normal. Hb 14; leu 9. BEST NEXT STEP IN MX? also Dx?
Dx alcohol withdrawal syndrome (AWS);
Next step: Administer i/v benzodiazepines
(9) alcohol withdrawal syndrome (AWS).
Alcohol use is often unreported or underreported in patients admitted to the hospital for medical treatment or surgical procedures. While being cared for in the hospital, this patient developed multiple symptoms and signs suggesting alcohol withdrawal syndrome (AWS).
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(9) alcohol withdrawal syndrome (AWS). table. mild withdrawal - onset since last drink?
6-24h.
(9) alcohol withdrawal syndrome (AWS). table. mild withdrawal - Symptoms?
anxiety, insomnia, tremors, diaphoresis, palpitations, GI upset, intact orientation
(9) alcohol withdrawal syndrome (AWS). table. Seizures - onset?
12-48
(9) alcohol withdrawal syndrome (AWS). table. Seizures - Symptoms?
Single or multiple generalized tonic-clonic
(9) alcohol withdrawal syndrome (AWS). table. Alcoholic hallucinations - onset?
12-48h
(9) alcohol withdrawal syndrome (AWS). table. Alcoholic hallucinations - symptoms?
Visual, auditory or tactile. Intact orientation; stable vital signs
(9) alcohol withdrawal syndrome (AWS). table. Delirium tremens - onset?
48-96
(9) alcohol withdrawal syndrome (AWS). table. Delirium tremens - symptoms?
confusion, agitation, fever, tachycardia, hypertension, diaphoresis, hallucinations
(9) alcohol withdrawal syndrome (AWS).
Alcohol depresses the CNS by binding to the GABAA receptor complex, enhancing the action of GABA, the major inhibitory neurotransmitter in the brain. With chronic alcohol use, these receptors become less sensitive and require more agonist (eg, alcohol) to counterbalance innate CNS excitatory signaling. Abrupt cessation of alcohol intake leads to rebound CNS overexcitation and the characteristic signs of AWS.
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(9) alcohol withdrawal syndrome (AWS). why BZD?
Benzodiazepines, which stimulate the GABA receptor and restore inhibitory tone, are first-line therapy to treat psychomotor agitation, prevent or treat withdrawal-induced seizures, and avoid progression to delirium tremens, which can be life threatening. Some patients require large doses of benzodiazepines to overcome GABA receptor desensitization.
(9) alcohol withdrawal syndrome (AWS). head CT scan?
CT scan of the head is not necessary to make the diagnosis of AWS. It may be indicated if there is seizure-induced head trauma (eg, to rule out traumatic hemorrhage) or if there are focal neurologic deficits inconsistent with typical withdrawal symptoms. However, neither is present in this patient, and the disorientation is consistent with a postictal state.
(10) A 42-year-old man is admitted to the hospital after sustaining fractures of his right femur and tibia in a motor vehicle collision. The patient becomes agitated, hypervigilant, and paranoid 12 hours after admission. He repeatedly tells the nurses that he can hear people in the corridor making insulting remarks about him. When hospital staff check the area near the patient’s room, no one is found. Medical history is unremarkable, but psychiatric history is significant for cocaine, marijuana, and alcohol misuse. He has smoked 2 packs of cigarettes a day for the past 10 years. On examination, the patient is alert and oriented. Temp. 37.2 C, BP 135/87, pulse 85/min, RR18/min. He is slightly tremulous and diaphoretic. Within 2 days, the patient’s hallucinations resolve, and his behavior returns to baseline. Soon after, he is discharged home. Which of the following is the most likely diagnosis in this patient?
ALCOHOLIC HALLUCINOSIS
(10). ALCOHOLIC HALLUCINOSIS. Alcoholic hallucinosis is an alcohol withdrawal syndrome characterized by hallucinations and relatively stable vital signs in an otherwise alert and oriented patient. Alcoholic hallucinosis typically presents after 12 hours of abstinence and resolves within 48 hours after the last drink. The condition is usually self-limited but can be managed with benzodiazepines.
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(10). ALCOHOLIC HALLUCINOSIS. Mx?
The condition is usually self-limited but can be managed with benzodiazepines.
(10). ALCOHOLIC HALLUCINOSIS. vs delirium tremens?
Alcoholic hallucinosis is distinct from delirium tremens even though both conditions frequently present with hallucinations.
Delirium tremens, which does not present prior to 48 hours after the last drink, is characterized by disorientation and marked sympathetic hyperactivity (eg, hyperthermia, hypertension, tachycardia) (Choice E). This patient is alert and oriented, his vital signs are normal, and his hallucinations fully resolved before 48 hours (ie, hospital day 2).
(10). ALCOHOLIC HALLUCINOSIS. vs cocaine withdrawal?
Cocaine withdrawal causes depression, anxiety, fatigue, and intense cravings. It is not commonly associated with psychosis.
(10). ALCOHOLIC HALLUCINOSIS. vs PCP?
Phencyclidine intoxication can present with psychosis in addition to combative behavior, delirium, dissociative symptoms, ataxia, and nystagmus. If this patient’s symptoms were due to phencyclidine intoxication, he would have been hallucinating immediately on presentation rather than a day later.
(11) A 51-year-old man is evaluated for agitation and oppositional behavior. The patient has a long history of schizophrenia. He was admitted to a group home yesterday after his mother, with whom he previously lived, moved to an assisted care facility. A staff member from the group home reports the patient was cooperative and calm when he arrived and did not talk much, which seems to be his baseline. He did not sleep well last night, and today he has been pacing and yelling at other residents and staff. The patient has no other medical conditions. Medications include clozapine. He does not use tobacco or recreational drugs but does use alcohol. Temperature is 36.7 C (98.1 F), blood pressure is 152/94 mm Hg, and pulse is 114/min. On physical examination, the patient appears anxious and diaphoretic and is fidgeting in his seat. Marked hand tremors are present. He is alert and oriented to person, place, and time. Which of the following is the best next step in management of this patient?
ADMINISTER BZD
(11) alcohol withdrawal.
Although it can go unrecognized, substance use disorder often occurs in patients with schizophrenia; up to 50% of patients with newly diagnosed schizophrenia already have a diagnosis of alcohol or drug use disorder.
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(11) alcohol withdrawal.
This patient with a history of schizophrenia and alcohol use has developed signs of alcohol withdrawal, likely precipitated by suddenly losing access to alcohol when he moved to a group home.
Clues to the diagnosis include the time course of symptoms (eg, calm and cooperative the first day, restless and agitated the second day) and manifestations of sympathetic hyperactivity (eg, elevated blood pressure, tachycardia, diaphoresis, and tremor).
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(11) alcohol withdrawal. Withdrawal symptoms typically start ??
within 6-24 hours after the last drink
(11) alcohol withdrawal.
Benzodiazepines are the treatment of choice for psychomotor agitation associated with alcohol withdrawal and to prevent progression to seizures and delirium.
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(12) An 8-year-old boy is brought to the office by his mother due to difficulties at school. The patient was adopted at age 2 from an orphanage. Medical history is significant for a heart murmur that resolved when he was an infant. His mother says, “His handwriting is illegible and the school wants to keep him back a grade. He has always struggled to sit still and focus; he is clumsy and breaks things without meaning to. He gets upset easily and throws things or hits his brothers when they don’t do what he wants.” The patient’s teacher has reported that he doesn’t listen, talks back, and distracts other children. Psychoeducational testing revealed an IQ score of 85. In the office, the boy is playing with a toy. When his mother takes it away, he hits her, starts crying, and becomes difficult to console. Vital signs are within normal limits. Weight and height are tracking at the 30th percentile, but head circumference is below the 10th percentile. Physical examination shows a thin upper lip and short palpebral fissures. Which of the following is the most likely diagnosis?
FETAL ALCOHOL SYNDROME
(12) FETAL ALCOHOL SYNDROME. Facial?
Smooth philtrum
Thin vermillion border
Small palpebral fissures
(12) FETAL ALCOHOL SYNDROME. Growth?
Height, weight and head circumference < 10th percentile
(12) FETAL ALCOHOL SYNDROME. Nonbehavioural?
Developmental delay
Cognitive impairment
Behavioral issues (eg ADHD, poor social skills)
Seizures
(12) FETAL ALCOHOL SYNDROME. Intrauterine alcohol exposure negatively impacts the fetal brain via inhibition of NMDA and hyperactivation of GABA receptors. Deficits in development of the corpus callosum, cerebellum, and basal ganglia result in abnormal reflexes, tone, and coordination, manifesting in this patient as difficulty with writing and clumsiness. A decrease in the volume of the frontal lobe and dysfunction of the amygdala result in deficits in executive functioning, impulse control, and emotion regulation. Features of attention-deficit hyperactivity disorder (ADHD) are common (Choice A). Other neurobehavioral manifestations include cognitive impairment, seizures, learning disabilities, and social skill deficits.
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(13) A 55-year-old woman comes to the office due to insomnia and fatigue that began shortly after her divorce was finalized a year ago. The patient used to sleep 7-8 hours without difficulty; however, over the past year she has had increasing difficulty falling asleep and started drinking 2-3 glasses of wine before bedtime to help. Despite falling asleep more quickly, she has recently started to regularly wake up around 3:00 AM. Her symptoms have progressively worsened and she now lies awake for several hours in the middle of the night, thinking and worrying about her future, but she rarely experiences anxiety during the day. She reports mild difficulty with concentration and no change in appetite. The patient experiences occasional brief sadness and loneliness. She has recently started showing up late for work and has stopped attending her weekly exercise class. Medical history includes hypothyroidism, treated with levothyroxine, and gastroesophageal reflux disease, diagnosed 3 months ago and treated with famotidine. Temperature is 37.2 C (99 F), blood pressure is 140/90 mm Hg, pulse is 90/min, and respirations are 12/min. Physical examination shows a mild tremor but no other abnormalities. Laboratory results are as follows: MCV 106, Hb 11,4. AST 85; ALT 42
Dx?
ALCOHOL USE DISORDER.
This patient’s alcohol consumption pattern (≥14 drinks per week), abnormal liver enzymes (AST/ALT ratio ≥2:1), macrocytosis, alcohol tolerance (ie, decreasing sedative effects of alcohol over time), and impaired functioning (eg, work tardiness) are consistent with a diagnosis of alcohol use disorder.
(13) ALCOHOL USE DISORDER.
negative health effects for women of all ages and men age ≥65 who consume >7 drinks in a week or >3 in a day (for men age <65, the cutoffs are >14 drinks in a week or >4 drinks in a day).
(13) ALCOHOL USE DISORDER.
Individuals with alcohol use disorder frequently seek primary care due to sleep disturbance and/or anxiety symptoms from mild withdrawal, as in this patient. These individuals may use alcohol to fall asleep, but as the blood alcohol level drops, CNS hyperarousal occurs and results in awakenings.
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