ALCOHOLISM:
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?
- Folate and vitamin B12 deficiency causing a megaloblastic anemia
- Anemia of chronic disease from chronic alcoholism
- Iron deficiency anemia
- Occult bleeding from Mallory-Weiss esophageal tear
- Ruptured gastroesophageal varices
Ans: 4
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.
excellent post.
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