We’re back with a USMLE® Step 2 CK Question of the Day! Today’s case involves a 38-year-old man arrives at the emergency department with anxiety and two recent episodes of loss of consciousness. His partner found him unconscious with urinary incontinence, and he’s been drinking more since losing his job four months ago. His vital signs are abnormal, and he exhibits signs of alcohol withdrawal. What additional historical element is likely present?
A 38-year-old man presents to the emergency department for evaluation of anxiety and two episodes of loss of consciousness over the past 24 hours. The patient’s partner recounts that they found the patient facedown on the lawn last night with urinary incontinence and again in the kitchen this morning. The partner states that the patient has been feeling down and drinking more alcohol than usual since losing his job four months ago: up to five beers a night. The patient has no significant past medical history. Temperature is 36°C (96.8°F), blood pressure is 168/60 mmHg, pulse is 110/min, respiratory rate is 16/min, oxygen saturation is 99% on room air. The patient is diaphoretic and anxious. He has evidence of tremor in the hands when the arms are outstretched and the fingers are spread. The underside of his tongue has a superficial laceration. Abdominal examination is unremarkable. IV access is established and the patient is given intravenous normal saline. Which of the following additional historical elements is most likely to be present?A. Recent cessation of alcohol use
B. Recent cessation of cocaine use
C. Anticholinergic ingestion
D. Recent cessation of chronic opioids
E. Isoniazid use
Scroll down for the correct answer!
The correct answer to today’s USMLE® Step 2 CK Question is…
A. Recent cessation of alcohol use
Before we get to the Main Explanation, let’s see why the answer wasn’t B, C, D, or E. Skip to the bottom if you want to see the correct answer right away!
Incorrect answer explanations
Today’s incorrect answers are…
B. Recent cessation of cocaine use
Incorrect: Cocaine withdrawal typically presents with symptoms similar to depression, including dysphoria, somnolence, and psychomotor retardation. Sympathetic hyperactivity and seizures are not usually present.
C. Anticholinergic ingestion
Incorrect: While anticholinergic overdose and alcohol withdrawal both present with symptoms of sympathetic hyperactivity, they can be distinguished by the presence or absence of diaphoresis. Anticholinergic effects result in anhidrosis.
D. Recent cessation of chronic opioids
Incorrect: Patients with opioid withdrawal can present similarly to patients with alcohol withdrawal. However, seizures are not typically seen in opioid withdrawal, and patients often have gastrointestinal symptoms (e.g. diarrhea, nausea, vomiting) with opioid withdrawal.
E. Isoniazid use
Incorrect: Isoniazid use can result in vitamin B6 deficiency and subsequent seizures. This patient has no historical features to suggest he has been taking isoniazid.
Main Explanation
This patient presents with evidence of sympathetic hyperactivity on physical exam and likely seizure activity (loss of consciousness associated with urinary incontinence and tongue biting). Based on these findings and a history of heavy alcohol use, recent alcohol cessation with subsequent alcohol withdrawal syndrome is likely.
Alcohol withdrawal refers to symptoms that develop in a patient with a history of heavy alcohol use when they either significantly reduce their alcohol intake or stop drinking entirely. Alcohol depresses the central nervous system. If alcohol intake drops after prolonged use, the patient will experience signs and symptoms due to hyperexcitability and hyperactivity of the central nervous system.
Patients with moderate to severe alcohol withdrawal syndrome can have evidence of sympathetic hyperactivity, including tachycardia, hypertension, tremors, insomnia, anxiety, diaphoresis, nausea, and vomiting. The severity of symptoms is often reflective of the duration and quantity of alcohol used with heavy use increasing the risk of severe withdrawal symptoms, including seizures, delirium tremens, and death. The first withdrawal symptoms can occur anywhere from several hours to one day after the last drink. Severe manifestations, such as confusion, hallucinations, and generalized tonic-clonic seizures, can occur 24 to 48 hours after alcohol cessation.
Major takeaway
Patients with alcohol withdrawal syndrome can present with signs and symptoms of sympathetic hyperactivity, such as insomnia, anxiety, palpitations, tachycardia, diaphoresis, and hypertension. Seizures and delirium tremens indicate severe alcohol withdrawal.
References
Wong, J., Saver, B. G., Scanlan, J., Gianutsos, L. P., Bhakta, Y., Walsh, J. J., Plawman, A. R., Sapienza, D., & Rudolf, V. (2020). The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management.JournalofAddictionMedicine,14(3S),1–72. https://doi.org/10.1097/adm.0000000000000668
Mayo-Smith MF, Beecher LH, Fischer TL, et al. Management of Alcohol Withdrawal Delirium: An Evidence-BasedPracticeGuideline.ArchInternMed.2004;164(13):1405–1412. doi:10.1001/archinte.164.13.1405
Bayard M, McIntyre J, Hill KR, Woodside J Jr. Alcohol withdrawal syndrome. Am Fam Physician. 2004 Mar 15;69(6):1443-50. PMID: 15053409.
Alcohol Use Disorders – Goldman-Cecil Medicine – ClinicalKey Student––––––––––––
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