ALCOHOLISM EXCLUSIVES/MCQ/PGQUESTIONS/NEET-PG

ALCOHOLISM EXCLUSIVES:

Q. 37-year-old man with a long history of alcoholism who is brought by ambulance to the ED severely agitated but oriented and cooperative. He is diaphoretic with vital signs stable at T 38.0°C; HR 98; BP 139/85; RR 24; SaO2 100%. He develops severe stuttering speech, a tongue wag, and generalized tremors, pronounced by intentional movement. He soon undergoes a generalized tonic-clonic seizure. Once he stops seizing, he is given longer-acting diazepam and is admitted to the hospital. He reports having had his last drink about 24 hours ago. What is his most likely diagnosis?

A. Withdrawal tremors and seizure

B. Delirium tremens

C. Alcoholic hallucinosis

D. Wernicke encephalopathy

E. Korsakoff syndrome

Ans: A. This presentation is consistent with withdrawal tremors and seizures, which occur within 48 hours after the last drink. Delirium tremens is unlikely, as this condition usually occurs after 48 hours and usually is accompanied by severe autonomic instability and vital sign fluctuations. He did not report visual hallucinations and therefore is not experiencing hallucinosis.Wernicke encephalopathy is an alcohol-induced organic brain symptom characterized by the classic triad of ataxia, ophthalmoplegia, and altered mental status. Korsakoff syndrome is a persistent amnesia with confabulation (mnemonic: K is for konfabulation). Both Wernicke and Korsakoff syndromes are caused by thiamine deficiency. These syndromes are usually present in the stable alcoholic patient. Given TN’s apparently normal mental status, these conditions are unlikely etiologies for his presentation.

Q.  A 52-year-old woman with a long history of alcoholism who presents complaining of fatigue and palpitations. She notes having passed foul-smelling, black stool in the last 2 days. Her recent history is significant for three episodes of vomiting and dry retching after an alcoholic binge. Generally, she appears well, with an HR of 96 and BP of 125/87. Her exam is significant for general pallor, diffuse epigastric tenderness, and heme-positive stool. Laboratory findings are significant for Hct of 32%, Plt 150,000/μL, and MCV of 85 fL. What is the most likely cause of her anemia?

1.  Folate and vitamin B12 deficiency causing a megaloblastic anemia
2.  Anemia of chronic disease from chronic alcoholism 
3.   Iron deficiency anemia 
4.  Occult bleeding from Mallory-Weiss esophageal    tear  
5. Ruptured gastroesophageal varices

Ans: D. Given the recent appearance of black stool and her normal MCV, it is likely that her anemia is caused by an acute event such as a Mallory-Weiss tear in her mucosa at the gastroesophageal junction caused by severe retching from excessive alcohol intake. Such a mucosal tear would produce moderate upper GI hemorrhage that appears as melena (black stool).

Chronic etiologies include iron, folate, and vitamin B12 deficiencies as well as anemia of chronic disease. Since her MCV is normal, it is unlikely that she has an iron deficiency anemia or anemia of chronic disease, which produce microcytic anemias. Folate or vitamin B12 deficiency would produce a macrocytic anemia. Lastly, although retching can rupture gastric varices, this would present with more profuse bleeding with frank hematochezia (bright red blood from the rectum), as well as a more fulminant clinical course.

Q. A 19-year-old boy is brought by ambulance after being found collapsed in his college dorm room by his roommate, “blue and not breathing on his own.” On the field, he is found to have an O2 saturation of 75% and is quickly intubated, which resolves his cyanosis, bringing his saturation to 100%. He hasa heart rate of 55 and a blood pressure of 95/55, for which he is given fluids. He has a GCS of 3, glucose of 85. He smells of alcohol and shows no signs of trauma. His pupils are equaland reactive, and the rest of his exam is normal. What is his most likely diagnosis?

A. Acute heroin overdose

B. Acute alcohol toxicity

C. Acute cocaine overdose

D. Insulin overdose

E. Acute BZD overdose

Ans: B. Ingestion of large amounts of alcohol  has been associated with CNS depression severe enough  to completely depress respiratory drive and result in death. Such severe intoxication must be treated with respiratory support until the patient can metabolize the alcohol. Heroin intoxication is less likely in this case, given the lack of stigmata like pinpoint pupils and track marks, although he can be given naloxone empirically. Benzodiazepine overdose is also possible but less likely. His vital signs and physical exam are inconsistent with a cocaine overdose. Lastly, his glucose level does not suggest an insulin overdose.

Q. 72-year-old man with a long history of alcoholism who is brought in by ambulance after having collapsed in his chair at home. He is eventually diagnosed with a hemorrhagic stroke. What is the most likely cause of this stroke?

A. Thiamine deficiency

B. Hypoglycemia

C. Korsakoff syndrome

D. Hepatic encephalopathy

E. Vitamin K deficiency

Ans: E.Vitamin K deficiency is associated with coagulopathy due to inability to produce sufficient coagulation factors. Such coagulopathy can predispose an individual to hemorrhagic strokes. Thiamine deficiency can produce altered mental status along with paresthesias. Long-term organic brain syndromes such as Korsakoff syndrome can cause amnestic symptoms with confabulation. Chronic liver disease can predispose someone to hypoglycemic events, which can manifest as syncope. Lastly, chronic liver insufficiency can produce high levels of serum ammonia, which can produce a hepatic encephalopathy and decreased sensorium.