{"id":759,"date":"2024-01-31T12:27:00","date_gmt":"2024-01-31T12:27:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=759"},"modified":"2026-06-30T15:16:24","modified_gmt":"2026-06-30T23:16:24","slug":"usmle-step-1-question-of-the-day-rehabilitation","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-rehabilitation","title":{"rendered":"USMLE\u00ae Step 1 Question of the Day: Rehabilitation"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-rehabilitation\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_1_Question_is%E2%80%A6\" >The correct answer to today&#8217;s USMLE\u00ae Step 1 Question is&#8230;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-rehabilitation\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-rehabilitation\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-rehabilitation\/#Major_Takeaway\" >Major Takeaway<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-rehabilitation\/#References\" >References<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><em>This week, we are sharing another <strong>USMLE\u00ae Step 1-style practice question<\/strong> to test your knowledge of <strong>medical <\/strong>topics. Today&#8217;s case focuses on a <strong>57-year-old man<\/strong> experiencing <strong>anxiety, hand tremor, <\/strong>and <strong>nausea post-total knee replacement<\/strong>, now in the emergency department. What&#8217;s your diagnosis?<\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A <strong>57-year-old man<\/strong> develops increasing <strong>anxiety, hand tremor, <\/strong>and <strong>nausea<\/strong> four days following an uncomplicated total <strong>knee replacement surgery<\/strong>. The patient is currently undergoing <strong>rehabilitation <\/strong>at a nearby facility and was transferred to the emergency department. Upon initial assessment, the patient states \u201cThere goes a bear!\u201d The patient is currently receiving a <strong>continuous infusion of intravenous morphine<\/strong>. Past medical history includes <strong><a href=\"https:\/\/www.osmosis.org\/learn\/Alcohol-induced_liver_disease\">advanced liver disease<\/a><\/strong>. The patient <strong>drinks seven cans of beer daily<\/strong>. He does not use tobacco or illicit drugs. <strong>Temperature is 37.5\u00b0C (99.5\u00b0F), pulse is 106\/min, respirations are 19\/min and blood pressure is 177\/60 mmHg. <\/strong>Physical examination shows a confused middle-aged man with <strong>slight tremulousness <\/strong>and <strong>diaphoresis<\/strong>. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Which of the following examination findings <em>may also be present<\/em> in this patient?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Miosis<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Nasal septum perforation<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Tongue fasciculations<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Vertical nystagmus<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Conjunctival injection<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down for the correct answer!<\/em><\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Learn with Osmosis\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/iDxHtjjCMbU?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_1_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s USMLE\u00ae Step 1 Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. &nbsp;Tongue fasciculations<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Before we get to the Main Explanation, let&#8217;s look at the incorrect answer explanations. Skip to the bottom if you want to see the correct answer right away!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Miosis<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;<strong>Miosis (pinpoint pupils)<\/strong> is a typical feature of <strong>opioid intoxication<\/strong>. Additional findings include <strong>depressed respiratory rate, depressed consciousness, hypotension, <\/strong>and <strong>bradycardia<\/strong>. This patient\u2019s history of <strong><a href=\"https:\/\/www.osmosis.org\/learn\/Alcohol_use_disorder\">chronic alcohol use<\/a><\/strong> and his current presentation with <strong>tremors, anxiety, <\/strong>and <strong>nausea<\/strong> instead suggest underlying <strong>alcohol withdrawal<\/strong>.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Nasal septum perforation&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;<strong>Cocaine intoxication<\/strong> manifests with <strong>agitation, diaphoresis, <\/strong>and <strong>mydriatic pupils<\/strong>. <strong>Nasal septum perforation<\/strong> may occur secondary to the caustic effects of the drug on the <strong>nasal mucosa<\/strong>. This patient\u2019s history of chronic alcohol use and his current presentation with tremors, anxiety, and nausea instead suggest underlying alcohol withdrawal.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Vertical nystagmus<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;<strong>Vertical nystagmus<\/strong> can be seen with <strong>alcohol intoxication<\/strong> or in <strong>phencyclidine (PCP) intoxication<\/strong>. &nbsp;PCP intoxication presents with <strong>agitation <\/strong>and <strong>aggression<\/strong> often requiring both <strong>chemical <\/strong>and <strong>physical restraints<\/strong>. This patient\u2019s history of chronic alcohol use and his current presentation with tremors, anxiety, and nausea instead suggest underlying alcohol withdrawal.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Conjunctival injection<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;<strong>Marijuana intoxication<\/strong> can present with <strong>perception of slowed time, euphoria, anxiety, paranoid delusions, impaired judgment, social withdrawal, increased appetite, dry mouth, <\/strong>and <strong>conjunctival injection<\/strong>. This patient\u2019s history of chronic alcohol use and his current presentation with tremors, anxiety, and nausea instead suggest underlying alcohol withdrawal.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This patient with a history of chronic alcohol use presents with evidence of tremors, anxiety, nausea, and <strong>transient hallucinations<\/strong>; this presentation is suggestive of alcohol withdrawal. <strong>Tongue fasciculations<\/strong> are a characteristic physical examination finding in patients with severe alcohol withdrawal.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The symptoms of alcohol withdrawal begin within <strong>12-24 hours of last consumption<\/strong> and are characterized by <strong>autonomic hyperactivity<\/strong>, tremor, insomnia, nausea and vomiting, transient hallucinations (usually visual but can also be auditory and tactile), <strong>psychomotor agitation<\/strong>, anxiety, and <strong>tonic-clonic seizures<\/strong>.&nbsp;Heavy, daily use of <strong>central nervous system (CNS) depressants<\/strong> (including alcohol) often results in withdrawal upon cessation of use. In general, withdrawal from depressants produces similar features: &nbsp;anxiety, tremor, seizures, and insomnia. In contrast, <strong>intoxication with CNS depressants<\/strong> manifests with <strong>elevated mood, sedation, behavioral disinhibition, <\/strong>and <strong>respiratory depression<\/strong>. The presentations of specific depressant intoxication and withdrawal features are summarized in the table below.<\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"840\" height=\"770\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/depressants-table.png\" alt=\"DEPRESSANTS\nDRUG \/ INTOXICATION \/ WITHDRAWAL\n\nALCOHOL \/ Slurred speech, Nystagmus, Disinhibited behavior, Incoordination, Ataxia, Memory impairment, Stupor, Coma \/ Alcohol craving, Tremor, Irritability, Nausea, Autonomic hyperactivity, Perceptual distortion, Seizures (6-48 hours after last drink), Visual (and occasionally auditory or tactile) hallucinations (12-48 hours after last drink), Delirium tremens (48-96 hours after last drink).\n\nOPIOD \/ Altered mental status, Reduced respiratory rate (rate &lt;12\/min is suggestive of opioid toxicity), Pinpoint pupils \/ Abdominal cramps, Nausea or vomiting, Rhinorrhea, Diasphoresis, Nasal congestion, Myalgias\n\nBARBITURATES \/ Sedation, Hypnosis, Coma, Suppressed respirations, Death \/ Cardiovascular collapse\n\nBENSODIASZEPINES \/ CNS depression, Lethargy \/ Sleep disturbances, Depression, Seizures\n\nINHALANTS \/ Euphoria, Anorexia, Gastrointestinal, Cardiovascular, Respiratory, Neurological symptoms \/ Irritability, Dysphoria, Sleep disturbance, Headache\n\" class=\"wp-image-761\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/depressants-table.png 840w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/depressants-table.png?resize=300,275 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/depressants-table.png?resize=768,704 768w\" sizes=\"auto, (max-width: 840px) 100vw, 840px\" \/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Withdrawal from <strong>sedatives <\/strong>(like alcohol) presents with anxiety, tremor, seizures, and insomnia, while <strong>intoxication with CNS depressants<\/strong> typically manifests with <strong>mood elevation, sedation, behavioral disinhibition, <\/strong>and <strong>respiratory depression<\/strong>. <strong>Psychomotor agitation<\/strong>, including <strong>tongue fasciculations<\/strong>, can be seen in severe alcohol withdrawal.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>O\u2019Brien C.P. (2017). Drug use disorders and addiction. Brunton L.L., &amp; Hilal-Dandan R, &amp; Knollmann B.C.(Eds.), Goodman &amp; Gilman&#8217;s: The Pharmacological Basis of Therapeutics, 13e. McGraw-Hill.<\/li>\n\n\n\n<li>Martin P.R. (2019). Substance-related and addictive disorders. Ebert M.H., &amp; Leckman J.F., &amp; Petrakis I.L.(Eds.), Current Diagnosis &amp; Treatment: Psychiatry, 3e. McGraw-Hill.<\/li>\n\n\n\n<li>Martin P.R. (2019). Substance-related and addictive disorders. Ebert M.H., &amp; Leckman J.F., &amp; Petrakis I.L.(Eds.), Current Diagnosis &amp; Treatment: Psychiatry, 3e. McGraw-Hill.<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image size-large\"><a href=\"https:\/\/www.osmosis.org\/ultimate-guide\/usmle-step-1\" target=\"_blank\" rel=\"noreferrer noopener\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/the-ultimate-guide-usmle-step-1-banner.png?w=700\" alt=\"\" class=\"wp-image-760\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/the-ultimate-guide-usmle-step-1-banner.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/the-ultimate-guide-usmle-step-1-banner.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><figcaption class=\"wp-element-caption\"><em><em><sub>The United States Medical Licensing Examination (USMLE\u00ae) is a joint program of the Federation of State Medical Boards (FSMB\u00ae) and National Board of Medical Examiners (NBME\u00ae). Osmosis is not affiliated with NBME nor FSMB.&nbsp;<\/sub><\/em><\/em><\/figcaption><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em>Want more <strong>USMLE\u00ae Step 1<\/strong> practice questions? Try <strong>Osmosis by Elsevier<\/strong> today! Access your&nbsp;<em><a href=\"https:\/\/www.osmosis.org\/plans\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>free trial<\/strong><\/a><\/em>&nbsp;and find out why millions of current and future <strong>clinicians and caregivers love learning by Osmosis<\/strong>.<\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Explore a USMLE\u00ae Step 1 question on alcohol withdrawal symptoms, including tongue fasciculations, anxiety, and tremors in a postoperative patient with chronic alcohol use.<\/p>\n","protected":false},"author":202,"featured_media":762,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,20,1366,1369,44],"tags":[885,733,888,886,84,279,221,451,887,185,889],"class_list":["post-759","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-questions","category-step-1-questions","category-step-1","tag-alcohol-withdrawal","tag-clinical-case","tag-cns-depressants","tag-exam-prep","tag-medical-education","tag-patient-assessment","tag-psychiatry","tag-step-1","tag-substance-use-disorder","tag-usmle","tag-withdrawal-symptoms"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - 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