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CSAM Exam Track
Presenter: James W. Golden, MD
1
Which statement regarding potential
side effects of buprenorphine is false?
A. It is generally well tolerated by the liver.
B. Elevated liver function tests (LFTs) at
baseline are a contraindication to
buprenorphine treatment.
C. LFTs should be monitored in patients on
buprenorphine.
D. Chronic buprenorphine is not generally
associated with cognitive impairment.
E. Buprenorphine is not usually associated
with QTc prolongation.
2
Answer is B.
Elevated LFT’s at baseline do not
necessarily exclude a patient from
buprenorphine maintenance treatment.
When taken as prescribed,
buprenorphine is generally welltolerated by the liver.
3
Which of the following is not a
predictable side effect of buprenorphine?
A. Constipation.
B. Diarrhea.
C. “Stimulated” feeling after taking the
dose.
D. Headache.
E. Nausea.
4
Answer is C.
Commonly reported side effects of
buprenorphine include constipation,
nausea, decreased interest in sex,
headache, upset stomach, feeling
groggy/sleepy after medication, and
diarrhea. A “stimulated” feeling is not
a side effect of buprenorphine. Most
side effects are mild in severity and
decrease as time in treatment
continues.
5
Drug hunger or drug craving with compulsive drug
seeking and drug taking, despite possible or known
negative consequences to the user, is defined as:
A.
B.
C.
D.
E.
Tolerance.
Dependence.
Addiction.
Withdrawal.
Abuse.
6
Answer is C.
Addiction is best defined as drug
hunger or drug craving with
compulsive drug seeking and drug
taking, despite possible or known
negative consequences to the user or
to others.
7
You are called to evaluate a patient in the emergency room for
possible opiate withdrawal. Which of the following signs or
symptoms are rarely seen in such circumstances?
A.
B.
C.
D.
E.
Spontaneous ejaculation.
Extreme restlessness.
Piloerection.
Convulsions.
Nausea and vomiting.
8
Answer is D.
Signs and symptoms of opiate
dependence in humans are dramatic
and occur within 6 to 12 hours after
the last dose of a short-acting opiate,
such as heroin.
9
The phenomenon by which a drug’s effectiveness
diminishes over time with regular use of the drug is a
definition of:
A.
B.
C.
D.
E.
Addiction.
Physical dependence.
Withdrawal syndrome.
Abuse.
Tolerance.
10
Answer is E.
Tolerance describes the phenomenon by
which a drug’s effectiveness diminishes
over time with regular use of the drug.
Addiction describes the compulsive use of a drug.
Physical dependence refers to the physiological state that follows
chronic, regular use, clinically evidenced by the emergency of a
characteristic withdrawal syndrome following significant reduction
in the amount of the drug regularly ingested.
Withdrawal syndrome is the physiological manifestation of nervous
system changes unmasked when the drug is no longer present.
11
Methadone may be used effectively to assist in withdrawing a patient
from opioids that are more addicting. However, this is only advised for
certain opioids. Addiction to which of the following is not appropriately
managed by using methadone substitution and eventual taper?
A.
B.
C.
D.
E.
Pentazocine.
Morphine.
Hydromorphone.
Oxycodone.
Heroin.
12
Answer is A.
In general, a more addictive drug should
not be used to detoxify a patient from a less
addictive one. Although methadone can be
used to withdraw patients from narcotics
such as heroin, morphine, hydromorphone,
oxycodone, or meperidine, it should be
avoided for drugs such as propoxyphene or
pentazocine, for which the withdrawal
should be handled by gradually decreasing
the dosage of the agent itself or by an
agent such as clonidine.
13
In the case of typical opioid withdrawal (e.g., from
chronic use of a short-acting opioid, such as heroin),
which of the following symptoms usually occurs first?
A.
B.
C.
D.
E.
Dysphoria.
Yawning.
Lacrimation.
Anxiety and craving.
Low-grade fever.
14
Answer is D.
When a short-acting opioid such as heroin
has been taken chronically, the onset of
withdrawal begins with anxiety and craving
about 8 to 12 hours after the last dose.
This progresses to dysphoria, yawning,
lacrimation, rhinorrhea, perspiration,
restlessness, and broken sleep. Later,
there are waves of gooseflesh, hot and cold
flashes, aching of bones and muscles,
nausea, vomiting, diarrhea, abdominal
cramps, weight loss, and low-grade fever.
15
Among various opioids, there may be clinically meaningful pharmacokinetic
differences that are reflected in different time courses for opioid withdrawal
phenomena. Which of the following opioids is notable for having the longest time
period from last drug use to development of withdrawal symptoms?
A.
B.
C.
D.
E.
Meperidine.
Methadone.
Heroin.
Morphine.
Hydromorphone.
16
Answer is B.
Methadone withdrawal symptoms
manifest between 36 and 72 hours
after use. Withdrawal symptoms for
meperidone, heroin, morphine, and
hydromorphone manifest 4 to 6 hours,
8 to 12 hours, and 4 to 5 hours after
use, respectively.
17
Adjunctive “comfort” medications are often helpful in managing
opioid withdrawal. Which of the following is used for flu-like
symptoms resulting from opioid withdrawal?
A. Nonsteroidal anti-inflammatory
drugs (NSAIDs).
B. Dicyclomine.
C. Bismuth subsalicylate.
D. Guanfacine.
E. Ondansetron.
18
Answer is D.
alpha-2 adrenergic agents for flu-like
symptoms (clonidine, guanfacine,
lofexidine)
NSAIDs for muscle cramps or pain (ibuprophen 600 to 800 mg every 6
to 8 hours, or ketorolac tromethamine intramuscularly every 6
hours for no more than five days)
dicyclomine for abdominal cramps (10 mg every 6 hours)
bismuth subsalicylate (30 cc after each loose stool)
prochlorperazine for nausea and vomiting (10 mg intramuscularly
three times a day or ondansetron 8 mg orally every 8 hours)
19
Buprenorphine has a mixed mechanism of
action at opioid receptors. What are its main
opioid receptor effects?
A.
B.
C.
D.
E.
Partial μ antagonist and κ agonist.
Partial μ agonist and κ antagonist.
Full μ antagonist and κ antagonist.
Partial μ agonist and κ agonist.
Full μ agonist and partial κ
antagonist.
20
Answer is B.
Buprenorphine is a partial μ opioid agonist
and κ antagonist that was synthesized in
1973 and initially used for the treatment of
pain. In the 1990s, there developed
growing evidence that buprenorphine was
also efficacious for the treatment of opioid
dependence; people addicted to heroin
submitted fewer opioid-positive urine tests
and reported less participation in illegal
activities while receiving sublingual
buprenorphine maintenance treatment.
21
Which statement regarding the
pharmacokinetics of buprenorphine is false?
A.
B.
C.
D.
It is highly lipid soluble.
It crosses the blood brain barrier.
It is highly protein bound.
Its primary metabolism by the liver
is by the cytochrome P450 2D6
isoenzyme.
E. Its primary metabolite is
norbuprenorphine.
22
Answer is D.
Buprenorphine is highly lipid soluble,
crosses the blood brain barrier,
circulates within the blood highly
plasma protein bound (96%), and
undergoes metabolism by the liver
primarily by the cytochrome P450 3A4
enzyme system. The primary
metabolite of buprenorphine is
norbuprenorphine, which is also a
partial μ opioid agonist.
23
There are a number of potential medication
interactions with methadone. Which of the following
medications may reduce plasma methadone levels?
A.
B.
C.
D.
E.
Risperidone.
Fluoxetine.
Sertraline.
Cimetidine.
Fluvoxamine.
24
Answer is A.
Risperidone may reduce plasma
methadone levels, while fluoxetine,
sertraline, cimetidine, and fluvoxamine
may increase them.
25
Which of the following statements concerning the
clinical pharmacology of methadone and levo-alpha
acetyl methadol (LAAM) is true?
A. LAAM has a shorter half-life than
methadone.
B. LAAM does not have any active
metabolites.
C. Methadone has two active metabolites.
D. Methadone acts as an N-methyl-Daspartate (NMDA) antagonist.
E. The abuse liability of LAAM is
significantly less than that of methadone.
26
Answer is D.
Methadone is a synthetic, long-acting, orally
available opioid that acts primarily as a
high-affinity agonist at μ and δ opiate
receptors. Methadone also acts s an NMDA
antagonist. LAAM, a methadone derivative
also approved by the FDA for opioid agonist
maintenance treatment, has a longer halflife than does methadone (2 days) and is
metabolized by cytochrome P450 (CYP)
enzymes (primarily CYP3A4) to two active
metabolites with half-lives of 2 days (norLAAM) and 4 days (dinor-LAAM).
27
The FDA recently added a black box warning in the
prescribing information of methadone. What was
the reason for the warning?
A. Increased mortality rate in seniors.
B. Impaired driving performance on
normal days.
C. Prolonged QTc interval.
D. Alterations of hypothalamicpituitary-adrenal (HPA) axis and
immune system functioning.
E. Long-term damage to the lungs.
28
Answer is C.
Recent reports indicate an association
between methadone and cardiac
conduction defects (prolonged QTc
interval) and torsades de pointes, an
association previously noted for LAAM.
A black box warning about these
effects was added to the prescribing
information for methadone in
December 2006.
29
Most studies of the effectiveness of maintenance
treatment with LAAM, methadone, or buprenorphine
have found that:
A. LAAM is superior to methadone and
buprenorphine.
B. Methadone is superior to LAAM and
buprenorphine.
C. Buprenorphine is superior to
methadone and LAAM.
D. Buprenorphine is superior to LAAM
but comparable to methadone.
E. All three agents are comparable.
30
Answer is E.
Most studies of the long-term effects of
treatment are based on methadone
maintenance, but shorter-term studies
(generally lasting up to 6 months)
suggest that the effectiveness of
maintenance treatment with LAAM or
buprenorphine is comparable with that
of methadone maintenance treatment.
31
The results of observational studies,
experimental human laboratory studies, and
randomized clinical trials have found that:
A. The effectiveness of methadone maintenance
treatment is not dose dependent.
B. The higher the methadone dose, the lower the
likelihood of illicit opioid use.
C. The beneficial effects of methadone maintenance on
health and social and vocational functioning occur
rapidly over a brief period of treatment.
D. If patients continue to receive enhanced psychosocial
services, methadone doses may be decreased without
substantially reducing the effectiveness of methadone
maintenance treatment.
E. Lower doses of methadone decrease the likelihood of
illicit opioid use.
32
Answer is B.
Taken together, the results of observational
studies, experimental human laboratory
studies, and randomized clinical trials are
compelling. Methadone maintenance dosedependently decreases illicit opioid use. Its
beneficial effects on health, social, and
vocational functioning may occur gradually
over prolonged periods and the effectiveness
of methadone maintenance treatment
diminishes substantially when methadone
doses are lowered or discontinued, even
when patients can continue to receive
enhanced psychosocial services.
33
Which of the following is a partial opiate
agonist?
A.
B.
C.
D.
E.
Methadone.
Buprenorphine.
Naloxone.
Nalmefene.
Naltrexone.
34
Answer is B.
For the treatment of opioid dependence, agonist
treatment with methadone and buprenorphine has
had the greatest impact. They are agonists in that
they have an affinity for opiate receptors, resulting
in binding to the receptor and activating it. Agonists
are effective for treatment of opiate dependence
mainly because they reduce opiate craving and
withdrawal symptoms, and confer tolerance to
opiates, thus reducing the euphoric effects of
additional opiates, such as heroin. Methadone is a
full agonist, where as buprenorphine is a partial
opiate agonist. Naloxone, nalmefene, and
naltrexone are opiate antagonists.
35
All of the following statements describe either benefits of
naltrexone treatment for opiate dependence or patient
populations who may respond well to naltrexone treatment
except:
A. Patients with a history of recent
employment do well on naltrexone.
B. Naltrexone may be prescribed by any
physician in his or her office.
C. Naltrexone has been shown to be effective
in treating opiate dependence even when
simply prescribed as a medication in the
absence of a structural rehabilitation
program.
D. Naltrexone is not a controlled substance.
E. Healthcare professionals have done well in
naltrexone treatment programs.
36
Answer is C.
Naltrexone is not effective when simply prescribed as a
medication for street heroin-addicted patients in the
absence of a structured rehabilitation program. Within
a structured program, naltrexone appears to be
effective, particularly with specific motivated
populations. Patients with a history of recent
employment and good educational backgrounds do well
on naltrexone. Some patients avoid methadone
because of required daily clinic visits. Because
naltrexone is not a controlled substance, greater
flexibility is permitted. It can be prescribed by any
physician in his or her office. Although highfunctioning patients may be strongly motivated to be
drug free, they remain susceptible to impulsive drug
use. Using naltrexone as a kind of “insurance” is often
a very appealing idea.
37
Which of the following statements
about naltrexone is true?
A. It is only available in parenteral
form.
B. It has low receptor affinity.
C. It is poorly absorbed from the gut.
D. It has a short duration of action.
E. It prevents opiate agonists from
binding to the receptor.
38
Answer is E.
Naltrexone is a relatively pure
antagonist in that it produces little or
no agonist activity at usual doses and
prevents opiate agonists from binding
to the receptor and producing opiate
effects. Naltrexone has high receptor
affinity, and thus it can block virtually
all the effects of the usual doses of
opioids and opiates such as heroin.
39
Nalmefene differs from naloxone primarily in
which of the following ways?
A. Nalmefene is available in parenteral
form.
B. Nalmefene is a pure agonist.
C. Nalmefene is available in an oral
form.
D. Nalmefene has a much longer
duration of action.
E. Nalmefene activates opiate
receptors.
40
Answer is D.
Nalmefene has a much longer duration
of action than naloxone. Both
nalmefene and naloxone are available
in parenteral and oral form. They are
antagonists and occupy opiate
receptors but do not activate them.
41
Which of the following statements about the
treatment of opiate dependence with
naltrexone is true?
A. Naltrexone is now available in a depot
preparation.
B. Naltrexone needs to be given daily.
C. Tolerance to the antagonism of opioid
effects develops after one year of
naltrexone treatment.
D. Naltrexone is not approved by the FDA to
treat alcoholism.
E. In the presence of naltrexone, heroin
self-administration is still rewarding.
42
Answer is A.
A depot preparation of naltrexone that is
effective with monthly dosing was approved by
the FDA for treatment of alcoholism in 2006.
This form of naltrexone is also effective against
opiate injections. At the present time, use of
depot naltrexone to treat opiate addiction is
considered to be an off-label use by the FDA.
Although daily ingestion of naltrexone would
provide the most secure protection against
opioid effects, naltrexone can be given as
infrequently as two or three times per week
with adequate protection against re-addiction to
street heroin.
43
According to the DEA, buprenorphine is:
A.
B.
C.
D.
E.
Schedule I
Schedule II
Schedule III
Schedule IV
Not scheduled.
44
Answer is C.
Buprenorphine is Schedule III.
It requires a prescription and has
moderate abuse potential.
45
Tramadol is:
A.
B.
C.
D.
E.
Schedule I
Schedule II
Schedule III
Schedule IV
Not scheduled.
46
Answer is E.
Tramadol is not scheduled.
A prescription is required.
47
What is the average dose necessary to achieve an
optimal treatment outcome for a patient in a
methadone maintenance program?
A.
B.
C.
D.
E.
30 mg/day.
40 mg/day.
50 mg/day.
80 mg/day.
140 mg/day.
48
Answer is D.
Multiple studies have confirmed
methadone doses in the range of 60 to
120 mg/day lead to superior outcomes
as compared to doses below this
range. No evidence suggests that
doses above 120 mg/day are
consistently more beneficial with
regard to outcome measures.
49
Which of the following opioids should not be
used in chronic pain patients with renal
insufficiency?
A.
B.
C.
D.
E.
Methadone.
Hydromorphone.
Butorphanol.
Meperidine.
Nalbuphine.
50
Answer is D.
Meperidine’s active metabolite,
normeperidine, can rapidly accumulate
in patients with renal disease and
cause seizures. All other choices are
opioids that can be used safely in
patients with renal insufficiency.
51
Methadone use for greater than 10
years has been associated with:
A.
B.
C.
D.
Increased liver function tests.
Cardiomyopathy.
Renal failure.
Constipation.
52
Answer is D.
Long-term methadone use is safe.
Constipation is a potential side effect of
all opioids that may be present.
53
Because it is often difficult to assess the degree of
physiological tolerance in a patient dependent on heroin, which
of the following is the optimal starting dose of methadone in an
inpatient setting?
A.
B.
C.
D.
E.
5 mg
20 mg
35 mg
40 mg
50 mg
54
Answer is B.
The safest starting dose that will
effectively suppress withdrawal in most
patients is 10 to 20 mg. Doses at 5
mg are likely too low to suppress
withdrawal. Doses close to or above
40 mg can potentially be fatal in
patients who do not have adequate
tolerance.
55
All of the following are true statements
regarding buprenorphine EXCEPT:
A. High oral bioavailability.
B. High affinity for the mu receptor.
C. Does not cause respiratory
depression at high doses.
D. Is a Schedule III narcotic.
56
Answer is A.
Buprenorphine is administered
sublingually due to its poor oral
bioavailability.
57
A 45-year-old man with a history of heroin dependence who has been stable
on methadone 70 mg p.o. daily for five years gets into a near-fatal car
accident. He fractures his jaw and is unable to take any medication by mouth.
What is the preferred way to manage his acute pain?
A. Convert the daily methadone dose to an equivalent
dose of intravenous morphine sulfate and administer
that dose.
B. Convert the daily methadone dose to an equivalent
dose of intravenous morphine sulfate and administer
one dose higher than that until the pain is
controlled.
C. Convert the daily methadone dose to an equivalent
dose of buprenorphine and administer that dose.
D. Give the equivalent dose of patient’s methadone in
divided intramuscular doses and then administer
higher than normal doses of short-acting parenteral
opioids to achieve pain control.
E. All of the above are preferred options.
58
Answer is D.
{
{
{
Because of the cross-tolerance to methadone, the
patient’s baseline methadone dose can be maintained by
giving intramuscular methadone in divided doses and then
treating the acute pain with higher than normal doses of
short-acting opioids.
Option B is a possibility, but would not be an optimal
choice because it would disrupt the steady-state plasma
level of methadone and patient would then have to be
reintroduced to methadone after the pain crisis has
resolved.
Giving the equivalent dose would not likely treat the acute
pain syndrome (Option A), and giving a partial
agonist/antagonist such as buprenorphine, could
precipitate opioid withdrawal (Option C).
59
A pragmatic approach to the treatment of persons at risk for
human immunodeficiency virus (HIV) infection that seeks
primarily to reduce the adverse health consequences of drug
abuse and other risk behaviors is referred to as:
A.
B.
C.
D.
E.
Consequence management.
Harm reduction.
Therapeutic compromise.
Acceptance approach.
Selective intervention.
60
Answer is B.
{
{
The “harm reduction” approach to high-risk
behaviors does not seek to eliminate the behavior,
seeing this goal often as unrealistic. Rather, it seeks
to modify key aspects of the behavior that must
directly lead to negative health consequences.
Examples of this strategy, which is a key feature of
many HIV prevention programs, are needle
exchange and condom distribution programs.
They are often controversial because their goals do
not include cessation of behaviors that many drug
treatment approaches and segments of the public
consider inherently harmful (e.g., substance abuse
and certain sexual behaviors.)
61
A medical student working in an HIV clinic is
accidentally stuck by a contaminated needle. What
is the student’s risk of seroconversion to HIV?
A.
B.
C.
D.
E.
<1.0%
5%
10%
15%
50%
62
Answer is A.
Risk of seroconversion to HIV after a
needle stick injury is approximately
0.3%. The risk of seroconversion to
Hepatitis B is estimated to be over 100
times more (around 30%).
63
Which of the following would NOT be safe in
a patient with severe Hepatitis C/liver failure?
A.
B.
C.
D.
Lorazepam.
Oxazepam.
Diazepam.
Temazepam.
64
Answer is C.
Diazepam.
Longer half-life with active metabolites.
Metabolized via microsomal oxidation.
Other choices all metabolized via
glucuronide conjugation, which is more
rapid with inactive metabolites.
65
All of the following are true regarding
the neurobiology of GHB except:
A. Specific high-affinity binding sites for
GHB have been identified in the rat
brain.
B. GHB is likely a neurotransmitter.
C. GHB seems to act directly on gammaaminobutyric acid (GABA) receptor sites.
D. GHB has been shown to stimulate growth
hormone release in humans.
E. LD50 and GHB is estimated to be only 5
times the intoxicating dose.
66
Answer is C.
GHB does not act directly on GABA
receptors; however, specific binding sites
for GHB have been discovered in rats.
Various lines of evidence suggest the GHB is
a neurotransmitter. GHB stimulates growth
hormone release up to 16-fold in humans,
perhaps explaining why it has been used by
bodybuilders. Its low therapeutic index
makes it particularly dangerous as a drug of
abuse.
67
All of the following are true statements
regarding the epidemiology of inhalant use
and misuse except:
A. Inhalant dependence is a relatively
uncommon disorder with lifetime
prevalence being approximately 0.3%.
B. Inhalant use is most common in the
adolescent population.
C. Although inhalant dependence is an
uncommon disorder, a large percentage
of individuals who try inhalants progress
to inhalant dependence.
D. Inhalant use declines after adolescence.
68
Answer is C.
Inhalant dependence is an uncommon
phenomenon. Only a small percentage
of people who ever try inhalants will
progress to develop a dependence
syndrome. Inhalant use is most
prevalent in adolescents with use
decreasing thereafter.
69
Which of the following is not a characteristic
of inhalant-induced persisting dementia?
A. It has been associated with toluene use.
B. It causes movement disorders similar to
other subcortical dementias.
C. It is associated predominantly with white
matter changes rather than gray matter
signs.
D. Prominent signs include inattention,
apathy, and memory problems.
E. It can cause an irreversible dementing
process.
70
Answer is B.
Inhalant-induced persisting dementia is
associated with white matter changes
rather than gray matter changes. This
disorder has mostly been described
with toluene misuse, does not cause
movement disorders, causes the
symptoms in Option D, and can be
irreversible.
71
Scenario
HISTORY: 30-year-old man evaluated in the ER for dull
substernal chest pressure for one hour with diaphoresis, mild
nausea, palpitations, and dyspnea. Pain began
approximately 6 hours after inhaling cocaine. He is a
cigarette smoker with a 12-pack-year history. There is no
history of premature coronary artery disease in his family.
No other medical problems. Takes no medication.
VITAL SIGNS: Blood pressure 154/88, equal in both arms.
Pulse 95. Respirations 20. BMI 23.
EXAM: Rapid regular rhythm, normal heart sounds, grade
1/6 early systolic murmur at the upper left sternal border.
EKG: Sinus tachycardia without ST-segment or T-wave
abnormalities, with a rate of 100/min.
72
Which of the following is most appropriate
management for this patient?
A.
B.
C.
D.
Coronary angiography.
Heparin intravenously.
Metoprolol intravenously.
Nitroglycerin sublingually.
73
Answer is D.
Nitroglycerin sublingually.
Vasodilator therapy is the primary
treatment of cocaine-induced chest
pain.
74
Scenario
HISTORY: 55-year-old man hospitalized for a two-week
history of jaundice and altered mental status. He has a 10year history of alcohol dependence and has failed several
attempts to stop drinking. Family reports he has been
drinking heavily every day until about three weeks ago.
VITAL SIGNS: Temperature 100° F. Blood pressure 90/60.
Pulse 120. Respirations 30. BMI 24.
EXAM: Patient is confused and lethargic. Scleral icterus.
No guarding on abdominal palpation. Liver edge is tender
and easily palpable 3 cm below the right costal margin. No
ascites, edema, or evidence of bleeding.
DIAGNOSTIC TESTING: Chest x-ray normal. Ultrasound
reveals enlarged, fatty liver with no nodules, ascites,
pericholecystic fluid, or bile duct dilatation. Blood and urine
cultures are negative.
75
In addition to enteral nutrition, which of the
following is the most appropriate
management for this patient?
A.
B.
C.
D.
Ceftriaxone.
Methylprednisolone.
Fresh frozen plasma.
Liver transplantation.
76
Answer is B.
Methylprednisolone.
Patients with severe alcoholic hepatitis,
as defined by a discriminant function
score of 32 or more, benefit from
corticosteroid therapy.
77
Scenario
HISTORY: 17-year-old male high school student presents to
ER one hour after having generalized tonic-clonic seizure
while eating breakfast with his family. He states he was out
late the night before and drank six cans of beer over the
course of the evening. He reports sudden involuntary jerks
of his arms this morning before the convulsion, and having
had similar jerks on awakening over the past two months
when sleep deprived. He reports no history of regular
alcohol or illicit substance abuse. He takes no medication.
EXAM: Physical and neurologic exam findings normal.
DIAGNOSTIC TESTING: CBC, serum electrolyte, plasma
glucose, and serum ethanol levels, as well as urine toxicology
screen, were all normal. CT scan of the head revealed no
abnormalities.
78
Which of the following is the most likely
diagnosis?
A.
B.
C.
D.
Alcohol withdrawal seizure.
Benign rolandic epilepsy.
Juvenile myoclonic epilepsy.
Temporal lobe epilepsy.
79
Answer is C.
Juvenile myoclonic epilepsy is
characterized by myoclonic and
generalized tonic-clonic seizures on
awakening that are often provoked by
sleep deprivation or alcohol.
80
Scenario
HISTORY: 32-year-old man presents to ER after
becoming disoriented, combative, and agitated
earlier in the day. He is accompanied by a friend,
who states patient has a history of alcohol and drug
abuse, including inhalants.
VITAL SIGNS: Temperature normal. Blood pressure
140/88. Pulse 98.
EXAM: Uncooperative and slightly disoriented.
Remainder of exam unremarkable.
81
LABORATORY DATA
Fasting glucose
Sodium
Potassium
Chloride
Bicarbonate
Blood urea nitrogen
Plasma osmolality
Serum creatinine
Serum ketones
Urinalysis
110 mg/dL (6.1 mmol/L)
142 mEq/L (142 mmol/L)
4.1 mEq/L (4.1 mmol/L)
109 mEq/L (109 mmol/L)
23 mEq/L (23 mmol/L)
18 mg/dL (6.4 mmol/L)
320 mosm/kg H2O (320 mmol/kg H2O)
1.1 mg/dL (97.2 µmol/L)
Positive
Trace glucose; 4+ ketones
Arterial blood gas studies (with patient breathing ambient air)
pH
7.4
PCO2
44 mmHg
PO2
92 mmHg
82
Which of the following is the most likely
cause of this patient’s clinical presentation?
A.
B.
C.
D.
E.
Alcoholic ketoacidosis.
Diabetic ketoacidosis.
Ethylene glycol.
Isopropyl alcohol.
Toluene.
83
Answer is D.
Isopropyl alcohol poisoning is
characterized by an increased osmolal
gap in the setting of positive serum
and urine ketones and does not cause
metabolic acidosis.
84
Inhalants can be used in several different ways. Which of the
following techniques involves concentrating the vapors in a
container and then inhaling them?
A.
B.
C.
D.
E.
Bagging.
Huffing.
Snorting.
Sniffing.
Spraying.
85
Answer is A.
Bagging refers to concentrating the vapors in
a bag and then inhaling. Huffing refers to
holding a cloth soaked in the inhalant to one’s
mouth and inhaling. Spraying refers to
directly spraying the inhalant into the mouth.
Snorting and sniffing are non-technical terms
to describe the intake of inhalants. Severity
of toxicity and abuse tends to progress from
spraying to huffing to bagging.
86
Which of the following statements regarding
inhalant dependence is incorrect?
A. It is associated with polysubstance
abuse.
B. It is associated with antisocial
personality disorder.
C. It is associated with later use of
intravenous drugs.
D. It is associated with narcissistic
personality disorder.
E. None of the above.
87
Answer is D.
Inhalant dependence is not associated
with narcissistic personality disorder.
Inhalant dependence is associated with
polysubstance use, antisocial
personality disorder, and the later use
of intravenous drugs.
88
Chronic use of toluene has been linked to all of the
following medical complications except:
A.
B.
C.
D.
E.
Goodpasture’s syndrome.
Renal tubular acidosis.
Hypokalemia.
Bone marrow suppression.
Optic neuropathy.
89
Answer is D.
All of these complications are
associated with toluene use except
bone marrow suppression, which has
been linked instead to benzene use.
90
Which of the following is most accurate
regarding laboratory testing for inhalant use?
A. Inhalants are relatively cheap to test for.
B. Inhalants have a long half-life and can
be detected for up to 2 weeks after last
use.
C. Inhalants are a heterogeneous group of
compounds that are difficult to test for.
D. Blood is the preferred method of testing.
91
Answer is C.
Inhalants are a heterogeneous group of
compounds, can be quite costly to test
for, and generally have very short halflives, all of which makes them difficult
to test for. Inhalants can be detected
by air and urine samples in addition to
blood.
92
The following are classes of opioid
receptors except:
A.
B.
C.
D.
E.
Mu.
Kappa.
Delta.
Orphanin FQ/nociceptin (OFQ/N).
Beta.
93
Answer is E.
Four major classes of opioid-like
receptors have been identified thus far:
mu, kappa, delta, and OFQ/N. Their
common characteristics include seven
transmembrane alpha helices and
coupling to G proteins.
94
Most available clinically available opioid
medications are:
A.
B.
C.
D.
E.
Delta antagonists.
Delta agonists.
Mu agonists.
OFQ/N partial agonists.
Kappa agonists.
95
Answer is C.
Most of the 20 clinically available drugs that
act in opioid receptors are prototypical mu
agonists. Their actions include analgesia,
altered mood (often euphoria), anxiolysis,
miosis, respiratory depression, inhibition of
some spinal reflexes, inhibition of
gastrointestinal motility, suppression of
cough, and suppression of corticotrophinreleasing factor and adrenocorticotropic
hormone release. Other effects may include
pruritis, nausea, and vomiting.
96
The negative reinforcement theory of opioid dependence
postulates a state of which of the following in the neural system
of the addict, leading to continued abuse of opioid substances?
A.
B.
C.
D.
E.
Deficit.
Instability.
Excessive dopamine.
Hyperexcitability.
Allostasis.
97
Answer is E.
The negative reinforcement model sees
addiction as an example of allostasis in
which a biological system fails to maintain a
homeostatic balance leading to a state
characterized by an abnormal set point.
This model sees brain reward and stress
response systems as being out of balance.
The stress response system is too sensitive,
whereas the reward system is not sensitive
enough. Ingestion of the opioid drug
temporarily moves the system closer to
homeostasis.
98
Which of the following statements is true
regarding the neurobiology of opioids?
A. About 40% of individuals who use any opioid for
nonmedical reasons develop opioid dependence.
B. The reward properties of opioid drugs are thought
to be mediated by increased release of glutamate
in the nucleus accumbens.
C. Acute tolerance to the effects of opioid drugs is
thought to be mediated by protein kinase C
phosphorylation of opioid receptors.
D. Withdrawal from long-acting opioids such as
methadone peaks at 48 to 72 hours.
E. Lengthening of the QT interval, caused by the
blocking of a specific sodium channel, is the
presumed mechanism of cases of levo-alphaacetylmethadol (LAAM)-associated sudden death.
99
Answer is C.
A type of acute tolerance to opioids that develops
over minutes may be mediated by protein kinase C
phosphorylation of mu and delta receptors.
According to the National Comorbidity Survey, 23%
of heroin users and 7.5% of all non-medical opioid
users developed opioid dependence. The reward
properties of opioids are felt to be mediated by
stimulation of dopamine release in the nucleus
accumbens. Withdrawal from methadone peaks on
the fifth or sixth day. LAAM-associated torsades de
pointes and sudden death are felt to be mediated
via blockade of a potassium channel.
100
Scenario
A 23-year-old man with schizoaffective
disorder (bipolar type) and opioid
dependence is on agonist therapy and
currently takes methadone 60 mg by mouth
daily, olanzapine 20 mg by mouth at
bedtime, and divalproex sodium 1,000 mg
by mouth twice per day. The patient is
treated in the outpatient setting and has
been stable for the past six months with no
drug use. After stopping his methadone
abruptly, he develops the acute onset of
paranoid ideation and auditory
hallucinations.
101
Which of the following is the most likely
explanation for this phenomenon?
A. The patient relapsed to using intravenous
heroin.
B. The patient relapsed to using alprazolam.
C. The patient is having an acute relapse
related to his schizoaffective disorder.
D. Opioids have known antipsychotic
properties and suddenly stopping use can
lead to a psychotic exacerbation.
102
Answer is D.
Opioids have known antipsychotic properties, and
patients can become psychotic upon abrupt
cessation use. Patients that become psychotic tend
to have an underlying psychotic spectrum disorder
or a severe personality disorder, especially
borderline personality disorder. Using heroin again
would protect against psychosis, and alprazolam is
not associated with psychosis.
Option C may be partially correct in that having
schizoaffective disorder might be a risk factor for
developing psychosis in this scenario; however,
option D more accurately explains the genesis of the
psychosis in this patient.
103
Which of the following signs and symptoms
are not associated with opioid withdrawal?
A.
B.
C.
D.
E.
Anxiety.
Increased respiration.
Lacrimation.
Mydriasis.
Miosis.
104
Answer is E.
All of the above are symptoms of
opioid withdrawal except miosis, which
is characteristic of opioid intoxication.
105
All of the following are potential uses of
buprenorphine except:
A. Transitioning patients form highdose methadone to naltrexone.
B. Detoxification from heroin.
C. Maintenance therapy for fentanyl
dependence.
D. Maintenance therapy for
hydrocodone dependence.
E. Rapid induction of naltrexone in
heroin-dependent patients.
106
Answer is A.
Although buprenorphine can be used to transition
patients from methadone to naltrexone, doing so is
difficult at doses above 40 mg of methadone
because of the high likelihood of precipitating
withdrawal symptoms. Therefore, patients are
usually titrated down to 40 mg of methadone before
this transition is attempted. Otherwise,
buprenorphine is used for detoxification and
maintenance purposes for patients with different
types of opioid dependence. Data support the use
of buprenorphine in the clinical scenario described in
Option E.
107
Which of the following medications is the
optimal treatment for the pregnant heroindependent patient?
A.
B.
C.
D.
Buprenorphine.
Levo-alpha-acetylmethadol (LAAM).
Naltrexone.
No opioid is safe to use during
pregnancy.
E. None of the above are correct.
108
Answer is E.
Methadone is accepted as the treatment of
choice in pregnancy because of its wellestablished safety profile. Drugs that can
possibly induce withdrawal in active heroindependent patients, such as naltrexone and
buprenorphine, put the patient at increased
risk to develop complications such as
miscarriage or premature birth due to the
effects of the withdrawal syndrome. LAAM
and buprenorphine’s safety has not been
well established in pregnant heroindependent patients.
109
Which of the following statements
about methadone is true?
A. Long-term methadone administration has been
associated with bone demineralization.
B. Medicines such as rifampin, carbamazepine, and
efavirenz inhibit metabolism of methadone.
C. Daily oral doses of 60 to 100 mg of methadone
are generally required to prevent or greatly
attenuate opioid withdrawal symptoms.
D. Methadone is rapidly and nearly completely
absorbed in the intestine.
E. Peak plasma levels occur 8 to 12 hours after oral
administration.
110
Answer is D.
Although methadone is rapidly absorbed in the
intestine, food or other factors that reduce gastric
emptying can slow absorption. Peak plasma levels
are achieved within 2 to 6 hours after oral
administration. Daily oral doses of 20 to 40 mg are
generally adequate to prevent or greatly attenuate
opiate withdrawal symptoms, but higher doses may
be required to reduce craving and more subtle
withdrawal, and to block the reinforcing effects of
heroin. When used as a maintenance treatment, no
long-term damage to any organ system has been
found. Inducers of cytochrome P450 enzymes, such
as rifampin, carbamazepine, phenytoin, and some
retrovirals, increase methadone metabolism and can
precipitate withdrawal.
111
All of the following are true regarding opioid
agonist maintenance therapy except:
A. The effectiveness of methadone and other opioid
agonist treatments for reducing morbidity, mortality,
and social dysfunction has been validated by several
meta-analytic studies.
B. Only about one-fifth of heroin-dependent individuals
are enrolled in agonist maintenance treatment.
C. When methadone maintenance treatment has been
made easily available at a low cost, and publicized,
90% or more heroin addicts have sought treatment.
D. Daily dosing of methadone above 100 mg per day
should be avoided because it is dangerous and rarely
helpful.
E. Patients who are provided minimal drug counseling
have been shown to be at substantially increased risk
of continued illicit drug use, despite adequate
methadone dosing.
112
Answer is D.
Although effective doses of methadone
generally are between 60 and 100 mg
daily, full attenuation of heroin effects
may only be seen at higher doses and
should be optimized based on
individual patient response.
113
While declining substantially in the general population between
1990 and 2000, the prevalence of what type of abuse has
remained endemic among opioid-dependent individuals?
A.
B.
C.
D.
E.
Marijuana.
Alcohol.
Ecstasy.
Methamphetamine.
Cocaine.
114
Answer is E.
While the prevalence of cocaine abuse and
dependence declined substantially in the general
population between 1990 and 2000, they have
remained endemic among opioid-dependent
individuals. Reported prevalence of frequent
cocaine use among new admissions to methadone
treatment ranges between 15% and 40%. Although
this prevalence decreases during maintenance
treatment, the patients who continue to use cocaine
remain at higher risk for illicit opiate use, infectious
diseases such as acquired immunodeficiency
syndrome (AIDS), and criminal activity.
115
All of the following are known uses of
opiate antagonists except:
A. To reverse the effects of an opioid
overdose.
B. To block the effects of endogenous
opioids in disease states such as cocaine
dependence where there are high levels
of endogenous opioids.
C. To prevent relapse in a patient detoxified
from an opioid.
D. To make the diagnosis of physical
dependence on opioids.
116
Answer is B.
Option B is correct because naltrexone
has been used in alcohol dependence,
not cocaine dependence, to block
endogenous opioids that are thought to
mediate relapse to alcohol.
Naloxone is used for the purposes
shown in options A and D, while
naltrexone is used for the purpose
shown in option C.
117
Which of the following is true regarding the
difference between naltrexone and naloxone?
A. Naltrexone is not well-absorbed
from the gastrointestinal tract,
unlike naloxone.
B. Naloxone is given orally, whereas
naltrexone is given parenterally.
C. Naltrexone has a long duration of
action as opposed to naloxone.
D. All of the above.
E. None of the above.
118
Answer is C.
Naltrexone, unlike naloxone, has a long
half-life, is well-absorbed from the
gastrointestinal tract, and is given
orally rather than parenterally.
119
Naltrexone is most efficacious when used in
all of the following treatment populations
except:
A.
B.
C.
D.
E.
Probationers.
Impaired physicians.
Impaired pharmacists.
Alcohol-dependent patients.
Homeless patients.
120
Answer is E.
Option E is correct because “middle class addicts,”
rather than addicts from lower socioeconomic
backgrounds, tend to be more highly motivated to
remain abstinent.
Although addicts from lower socioeconomic
backgrounds can and do benefit from naltrexone,
they tend to have less incentive to take it.
Naltrexone is also helpful in other highly motivated
populations who will pay a considerable penalty for
relapse (i.e., jail in option A or revocation of license
in options B and C). Naltrexone has been used in
patients with alcohol dependence to prevent relapse.
121
Which of the following is not a difference
between methadone and naltrexone?
A. Methadone is an effective treatment for the
severe heroin-dependent patient, whereas
naltrexone is not.
B. Unlike methadone, naltrexone cannot be given
until all opioids have been cleared from the body.
C. Unlike methadone, naltrexone has no intrinsic
opioidergic properties.
D. Unlike naltrexone, methadone does not block the
effects of opioids.
E. Unlike methadone, naltrexone does not produce a
physical dependence syndrome.
122
Answer is A.
Option A is correct because both
methadone and naltrexone are
treatments for heroin-dependent
patients, irrespective of severity.
Although many severe heroin addicts
will prefer methadone over naltrexone,
naltrexone is still a viable, important
option for them.
123
All of the following are true regarding
the use of naltrexone except:
A. If the naloxone challenge test is
negative, naltrexone can be started at a
25 mg dose.
B. The usual daily dose is 50 mg by mouth
daily.
C. Observing the ingestion of naltrexone is
not an essential part of treatment for
opioid dependence.
D. After one to two weeks, it is possible to
give naltrexone three times per week.
124
Answer is C.
Naltrexone is a useful treatment but
compliance in taking it is often a problem in
the opioid-dependent patient population.
Therefore, most practitioners recommend
observed or monitored pill ingestion.
The initial dose is 25 mg after the naloxone
challenge (Option A), the usual dose is 50
mg (Option B), and the drug can be
eventually given three times per week
because of its long half-life (Option D).
125
Most users of inhalants are:
A. Heroin addicts looking for a
substitute drug.
B. Young and not drug sophisticated.
C. Blue collar workers.
D. Housewives.
E. Asthmatic patients.
126
Answer is B.
Young and not drug sophisticated.
127
Inhalants are used for all the following
reasons except:
A.
B.
C.
D.
E.
Inexpensive.
Easily obtainable.
Rapid onset.
Impact dissipates very slowly.
Mild hangover.
128
Answer is D.
Impact dissipates very slowly.
129
At autopsy, the observation that would suggest
death from abuse of volatile hydrocarbons is:
A. Multiple infarctions of the cerebral
cortex.
B. Pulmonary talc granulomas.
C. Periarteritis nodosa.
D. Cirrhosis.
E. Exogenous pigmentation on the
hands and face.
130
Answer is E.
Exogenous pigmentation on the
hands and face.
131
Chronic use of nitrous oxide commonly
leads to:
A.
B.
C.
D.
E.
Microcytic anemia.
Inflammatory bronchitis.
Proteinuria.
Cardiac arrhythmias.
Sensorimotor polyneuropathy.
132
Answer is E.
Sensorimotor polyneuropathy.
133
Physical signs and symptoms of acute toxic
reactions to inhalants include all of the
following EXCEPT:
A.
B.
C.
D.
E.
Cardiac arrhythmias.
Pupillary dilation.
Rapid loss of consciousness.
Respiratory depression.
Urinary incontinence.
134
Answer is D.
Urinary incontinence.
135
Chronic solvent inhalation has been found to
be associated with all of the following
EXCEPT:
A.
B.
C.
D.
E.
Peripheral neuropathy.
Chronic paranoia.
Organic brain syndrome.
Increased sexual sensitivity.
Bone marrow disorders.
136
Answer is D.
Increased sexual sensitivity.
137
All of the following are true concerning
inhalant abuse EXCEPT:
A.
Solvents are all fat-soluble organic substances
that easily pass through the blood-brain barrier.
B. Cross-tolerance to other solvents and
withdrawal symptoms are commonly seen in
inhalant abusers.
C. Glue, paint thinners, aerosols, and nail polish
removers are commonly abused substances.
D. There are no specific antidotes for solvent
overdoses.
E. The most frequently neurologic positive finding
in inhalant overdoses is an EEG pattern of
diffuse encephalopathy.
138
Answer is B.
Cross-tolerance to other solvents
and withdrawal symptoms are
commonly seen in inhalant abusers.
139
Methadone was originally synthesized
in:
A.
B.
C.
D.
E.
Australia.
Europe.
Latin America.
The Middle East.
North America.
140
Answer is B.
Europe.
141
Match the most appropriate letter with
the syndrome:
1.
2.
3.
4.
5.
6.
___
___
___
___
___
___
Texas shoe shine
Snappers and poppers
Whippet
Huffing
Torch-ing
Robo-ing
A. Nitrous oxide
B. Amyl nitrate
C. Trichloroethylene
D. Butane
E. Toluene
F. Dextromethorphan
142
ANSWERS
1.
2.
3.
4.
5.
6.
_E_ Texas shoe shine
_B_ Snappers and poppers
_A_ Whippet
_C_ Huffing
_D_ Torch-ing
_F_ Robo-ing
A. Nitrous oxide
B. Amyl nitrate
C. Trichloroethylene
D. Butane
E. Toluene
F. Dextromethorphan
143
Scenario
HISTORY: An 18-year-old man is evaluated in the ER after
his mother found him unconscious in his bed at home. She
reported her son had gone to a party two nights ago, but she
was not sure when he returned home. When she checked on
him, he was unarousable. He has no significant medical
history and takes no medications.
VITAL SIGNS: In the ER, he is afebrile. Blood pressure
110/70, pulse 50, respirations 6. he is intubated for airway
protection.
DIAGNOSTIC TESTING: Alkaline phosphatase, bilirubin and
albumin are normal. Urine dipstick 4+ positive for occult
blood. Blood alcohol level is 0.8g/dL (174 mmo/L).
Toxicology testing is positive for opiates and cocaine.
Bladder catheterization reveals only 30 mL of brown urine.
144
Which of the following is the most likely
cause of the patient’s renal failure?
A.
B.
C.
D.
E.
Hemolytic anemia.
Hemolytic-uremic syndrome.
Hepatorenal syndrome.
Rhabdomyolysis.
Sepsis.
145
Answer is D.
Rhabdomyolysis.
Non-traumatic causes of
rhabdomyolysis including drug use,
metabolic disorders, and infections.
146
Scenario
A 22-year-old man is evaluated in the ER for a 12hour history of mild headache, nausea, and
vomiting. His roommate had similar symptoms the
previous day. He is given intravenous fluids and
prochlorperazine and begins to feel better until his
head suddenly becomes stiff and turns to the right.
He cannot move it to the midline or to the left. He
reports cramping and aching in the right neck
muscles.
EXAM: Neurologic exam shows the head to be
turned to the right with sustained contraction of the
left sternocleidomastoid muscle but is otherwise
unremarkable.
147
Which of the following is the best
treatment for this patient?
A.
B.
C.
D.
Benztropine.
Botulinum toxin.
Phenytoin.
Recombinant tissue plasminogen
activator.
E. Tetanus immune globulin.
148
Answer is A.
Benztropine.
Medications that block dopamine
receptors can cause acute dystonic
reactions, which can be readily
treated with benztropine.
149
Scenario
A 55-year-old woman is evaluated for elevated liver
chemistry tests detected on examination for life
insurance. She has no symptoms of liver disease
and no history of jaundice, ascites, lower extremity
edema, or encephalopathy. She used recreational
injection drugs between ages 20 and 25 years. She
has no significant medical history and takes no
medications. She drinks about six cans of beer a
day.
EXAM: Vital signs normal. Spider angiomata on the
upper body and the presence of a nodular liver edge
and splenomegaly.
150
LABORATORY DATA
Platelet count
INR
Bilirubin (total)
Aspartate aminotransferase
Alanine aminotransferase
Alkaline phosphatase
Albumin
Hepatitis B surface antigen
Hepatitis C virus antibody
HCV RNA in serum
88,000μL (88 x 109/L)
1.4
1.1 mg/dL (18.8μmol/L)
48 U/L
96 U/L
186 U/L
3.6 g/dL (36g/L)
Negative
Positive
500,000 copies/mL
151
DIAGNOSTIC DATA: Ultrasonography
shows coarsened hepatic echotexture.
CT scan shows changes in the liver
consistent with cirrhosis and
splenomegaly.
152
Which of the following is the most
appropriate next step in the management of
this patient?
A.
B.
C.
D.
Esophagogastroduodenoscopy.
Evaluation for liver transplantation.
Lamivudine.
Pegylated interferon and ribavirin.
153
Answer is A.
Esophagogastroduodenoscopy.
Variceal hemorrhage occurs in 25% to
40% of patients with cirrhosis. Upper
endoscopy is indicated in patients
with newly diagnosed cirrhosis.
154
Scenario
A 54-year-old man with a one-year history of
Parkinson disease is brought to the office by his
wife, who is concerned about her husband’s recent
excessive gambling. She says that in the past six
(6) months, he has been spending increasing
amounts of time at a casino, where he rarely
enjoyed going before the diagnosis of Parkinson
disease. His behavior is otherwise unchanged. The
patient has been taking ropinirole since the
diagnosis and has had a marked diminution in
tremor as a result. He has had no difficulties with or
change in mood, cognition, or sleep.
155
EXAM: General physical exam
findings are normal. Neurologic exam
shows normal speech, language,
mood, and mental status. There is
mild left upper limb rigidity and a
minimal resting tremor, but no other
abnormalities are detected.
156
Which of the following is the most likely
cause of the patient’s gambling problem?
A. Bipolar disorder.
B. Frontotemporal dementia.
C. Medication-related compulsive
behavior.
D. Parkinson-related dementia.
157
Answer is C.
Medication-related compulsive
behavior.
A potential adverse effect of
dopamine agonist therapy is the
development of compulsive behaviors
such as pathologic gambling,
shopping, and hypersexuality.
158
Scenario
A 30-year-old man is evaluated in the ER for a 3week history of malaise, fatigue, and jaundice.
Patient is an injection drug user and was diagnosed
with chronic hepatitis B virus infection 4 years ago.
He drinks beer occasionally and does not use any
medications, including over-the-counter
medications.
VITAL SIGNS: Temperature 36.1 C. (97.0 F.) Blood
pressure 120/65 mmHg, pulse 100, respirations 16.
EXAM: Abdomen reveals mild tenderness to
palpation in the right upper quadrant.
159
LABORATORY DATA
INR
1.2
Bilirubin (total)
3.5 mg/dL (59.9 μmol/L)
Bilirubin (direct)
1.8 mg/dL (30.8 μmol/L)
Aspartate aminotransferase
1100 U/L
Alanine aminotransferase
1450 U/L
Hepatitis B surface antigen
Positive
Hepatitis B core antibody (IgG) Positive
Hepatitis B core antibody (IgM) Negative
Hepatitis B virus DNA
Negative
Hepatitis C virus antibody
Negative
Acetaminophen
Negative
DIAGNOSTIC DATA: Ultrasonography shows
heterogeneous hepatic echotexture with no masses.
160
Which of the following is the most likely
diagnosis?
A. Acute alcoholic hepatitis.
B. Hepatitis delta virus
superinfection.
C. Hepatocellular carcinoma.
D. Reactivated hepatitis B virus
infection.
161
Answer is B.
Hepatitis delta virus superinfection.
Chronic carriers of hepatitis B are
susceptible to superinfection with
hepatitis delta virus, which is a
defective virus that requires the
presence of hepatitis B virus to exist.
162
Scenario
A 38-year-old man is admitted to the hospital for a 12hour history of bilateral lower-extremity paralysis.
Patient is an injection drug user. Over the past week,
he developed lower back pain, which progressed to
pain and numbness radiating down both lower
extremities. One the day of admission, he was unable
to walk but continued to use injection drugs.
VITAL SIGNS: Normal, including temperature.
CARDIAC: Regular rhythm and grade 2/6 holosystolic
murmur heard at the apex and radiating to the axilla.
NEUROLOGIC: 0/5 strength in both lower extremities
and absent sensation in both legs.
163
RADIOLOGY: Emergent MRI of the spine
shows evidence of osteomyelitis of the L1
and L2 vertebrae, diskitis of the L1-L2
disk space, and an epidural fluid collection
compressing the spinal cord.
LABORATORY: Three blood cultures were
drawn.
PLAN: Empiric therapy with vancomycin
and ceftazidime was initiated.
164
In addition to continuing antimicrobial
therapy, which of the following is the most
appropriate management?
A. CT-guided aspiration of the
epidural fluid collection.
B. Electromyography of the lower
extremities.
C. Emergent laminectomy.
D. Lumbar puncture.
165
Answer is C.
Emergent laminectomy should be
performed in patients with spinal
epidural abscess and neurologic
dysfunction of less than 24 to 36
hours’ duration.
166
Scenario
A 57-year-old woman is evaluated in ICU for rapidly
progressive renal failure requiring dialysis. Patient
had been hospitalized for advanced liver disease
including mental status changes secondary to
encephalopathy. She has ascites. Liver disease is
the result of chronic hepatitis C virus infection.
Patient has no history of renal insufficiency and has
not received antibiotics, intravenous contrast
agents, or other nephrotoxic agents. Medications
include lactulose, nadolol, midodrine, octreotide, and
albumin. She does not drink alcohol.
167
VITAL SIGNS: Temperature 36.6 C. (97.8 F.), blood
pressure 110/70 mmHg, pulse 97, respirations 12.
BMI is 22.
LABORATORY
Creatinine
Urea nitrogen
Urine sodium
Urinalysis
5.4 mg/dL (412.0 μmol/L)
120 mg/dL (42.8 mmol/L)
less than 5 mEq/L (5 mmol/L)
Negative
ULTRASOUND: Normal-size kidneys and no
obstruction.
168
Which of the following is the most
appropriate management?
A.
B.
C.
D.
E.
Add lisinopril.
Kidney and liver transplantation.
Kidney transplantation.
Liver transplantation.
Peritoneovenous shunt.
169
Answer is D.
Liver transplantation.
Patient has hepatorenal syndrome.
The diagnosis is made in the absence
of other causes of renal disease in the
setting of advanced liver disease.
170
Scenario
47-year-old man with long-standing history of alcoholism
is hospitalized for abdominal pain, nausea, and vomiting
of 7 days’ duration. His last drink was 6 days ago. He
has lost approximately 10% of his body weight over the
past 4 months. He states his weight loss was caused by
drinking alcohol and not eating.
GENERAL: Appears cachectic.
VITAL SIGNS: Temperature 37.1 C. (98.8 F.), blood
pressure 100/70 mmHg, pulse 110, respirations 18. BMI
is 17.
ABDOMINAL: Midepigastric tenderness without rebound.
Bowel sounds are present.
NEUROLOGIC: He is not confused or tremulous.
Neurologic exam normal.
171
LABORATORY
Amylase
Lipase
Sodium
Potassium
Chloride
Bicarbonate
Phosphorus
Calcium
Urinalysis
300 U/L
150 U/L
130 mEq/L (130 mmol/L)
3.4 mEq/L (3.4 mmol/L)
90 mEq/L (90 mmol/L)
20 mEq/L (20 mmol/L)
3.5 mg/dL (1.1 mmol/L)
9.0 mg/dL (2.2 mmol/L)
Positive for ketones
172
Patient receives immediate thiamine
replacement, folic acid supplementation, and
multivitamin followed by vigorous intravenous
fluid replacement with 5% dextrose and
normal saline with aggressive potassium
replacement. Morphine is used to control
pain.
Eighteen (18) hours later, patient’s abdominal
pain has improved but he becomes restless,
agitated, and extremely weak. He is barely
able to raise his extremities against gravity.
173
Which of the following is the most likely
cause of the patient’s new finding?
A.
B.
C.
D.
Hypercalcemia.
Hypokalemia.
Hyponatremia.
Hypophosphatemia.
174
Answer is D.
Hypophosphatemia.
In the hospital setting, patients with
chronic alcoholism may have normal
serum phosphorus levels on
admission, but often develop severe
hypophosphatemia over the first 12
to 24 hours.
175
Scenario
A 20-year-old woman is evaluated in the ER for
generalized tonic-clonic seizure. She is
accompanied by a friend who states the patient took
“something” several hours earlier.
VITAL SIGNS: Temperature 38.8 C. (100.0 F.),
blood pressure 90/50 mmHg, respirations 24.
NEUROLOGIC: Unresponsive to painful stimuli, but
there are no localizing neurologic findings.
Remainder of the physical exam is unremarkable.
176
LABORATORY
Sodium
Potassium
Chloride
Bicarbonate
Blood urea nitrogen
Serum creatinine
118 mEq/L (118 mmol/L)
4.1 mEq/L (4.1 mmol/L)
90 mEq/L (90 mmol/L)
19 mEq/L (19 mmol/L)
18 mg/dL (6.4 mmol/L)
0.9 mg/dL (79.6 μmol/L)
177
What is the most likely substance the
patient ingested?
A. GHB.
B. Ecstasy.
(3,4-methylenedioxymethamphetamine)
C. Ketamine.
D. Cocaine.
E. Ethyl Alcohol.
178
Answer is B.
Ecstasy
(3,4-methylenedioxymethamphetamine)
179
Which of the following is the most
appropriate next step in this patient’s
management?
A.
B.
C.
D.
3% saline infusion.
Intravenous conivaptan.
Intravenous desmopressin.
Intravenous furosemide.
180
Answer is A.
3% saline infusion.
Patient has acute hyponatremia.
Rapid normalization of the
extracellular fluid osmolality with
hypertonic saline is indicated.
181
Each letter may be used more than
once or not at all:
A.
B.
C.
D.
E.
F.
Nitrous oxide.
Toluene.
Benzene.
Cyanide.
Amyl nitrate.
Ethylene glycol.
__ Subacute combined spinal cord degeneration
__ Methemoglobinemia
__ Distal renal tubular acidosis
182
ANSWERS
A.
B.
C.
D.
E.
F.
Nitrous oxide.
Toluene.
Benzene.
Cyanide.
Amyl nitrate.
Ethylene glycol.
__A_ Subacute combined spinal cord degeneration
__E_ Methemoglobinemia
__B_ Distal renal tubular acidosis
183
Each letter may be used more than
once or not at all:
A.
B.
C.
D.
E.
F.
Nitrous oxide.
Toluene.
Benzene.
Cyanide.
Amyl nitrate.
Ethylene glycol.
___ Vitamin B-12 deficiency.
___ Non-glomerular hematuria.
___ Cerebellar ataxia.
184
ANSWERS
A.
B.
C.
D.
E.
F.
Nitrous oxide.
Toluene.
Benzene.
Cyanide.
Amyl nitrate.
Ethylene glycol.
_A_ Vitamin B-12 deficiency.
_C_ Non-glomerular hematuria.
_B_ Cerebellar ataxia.
185
Each letter may be used more than
once or not at all:
A.
B.
C.
D.
E.
F.
Nitrous oxide.
Toluene.
Benzene.
Cyanide.
Amyl nitrate.
Ethylene glycol.
___ Glue sniffing.
___ Hypokalemia.
___ Pneumomediastinum.
186
ANSWERS
A.
B.
C.
D.
E.
F.
Nitrous oxide.
Toluene.
Benzene.
Cyanide.
Amyl nitrate.
Ethylene glycol.
_B_ Glue sniffing.
_B_ Hypokalemia.
_A_ Pneumomediastinum.
187
Each letter may be used more than
once or not at all:
A.
B.
C.
D.
E.
F.
Nitrous oxide.
Toluene.
Benzene.
Cyanide.
Amyl nitrate.
Ethylene glycol.
___ Metabolic acidosis (anion gap).
___ Bone marrow aplasia.
188
Each letter may be used more than
once or not at all:
A.
B.
C.
D.
E.
F.
Nitrous oxide.
Toluene.
Benzene.
Cyanide.
Amyl nitrate.
Ethylene glycol.
_F_ Metabolic acidosis (anion gap).
_C_ Bone marrow aplasia.
189
REFERENCES
Psychiatry Online, www.psychiatryonline.com
Addiction Medicine Review Course 2008
American College of Physicians, Internal Medicine Self-Assessments
Josiah Macy Jr. Foundation, Utilizing standardized patient protocols: To
Improve Clinical Skills in Identifying Tobacco, Alcohol and Other Drug Use
190