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ANs:
What would be the best approach to evaluating this patient for alcoholism
Ans: A
Upon further questioning, you begin to uncover a long history of heavy drinking. Which of the following statements about this patient is true
Ans: B
This patient reports to you that she has needed to drink increasing amounts of alcohol to help her fall asleep.
Ans: B
This patient is most likely to have
Ans:E
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Harry,
Your question will be answered in the next question 
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lorazepam/oxazepam for alcohol withdrawal in liver disease
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-Discussion
The correct answer is D. The defense mechanism of denial is so strongly evident in alcoholism that the best approach is to explore how alcohol affects her life, rather than direct questions about drinking behavior. Information from family and friends will provide a more accurate account of the problem. Laboratory workups cannot be relied upon to make the diagnosis. The CAGE questionnaire is a very brief and useful screening tool, employed effectively in the primary care
setting. A positive answer to 2 or more questions is very sensitive and specific for an alcohol use disorder. It consists of asking the patient the following 4 questions: Have you ever
C: felt that you should Cut Down on your drinking?
A: been Annoyed that people criticized your drinking?
G: felt bad or Guilty about your drinking?
E: taken a drink first thing in the morning (Eye
Opener) to get rid of a hangover or steady your nerves?
-Discussion
The correct answer is B. Peripheral neuropathy can be seen in 10% of heavy drinkers as a result of vitamin deficiencies and the direct impact alcohol has on nerve function. Answer A is incorrect because cerebellar degeneration”suggested by ataxia and nystagmus”does occur as a result of alcohol overuse. Answer C is incorrect because alcoholic œfatty liver will reverse
with abstinence from alcohol. Answer D is incorrect. Heavy drinking raises blood pressure and levels of triglycerides, increasing risk of myocardial infarction. Finally, E is incorrect. Heavy drinking lowers the white blood cell count and interferes with specific aspects of the immune system; for example, it compromises T-cell function.
- Discussion
The correct answer is C. Tolerance is defined as the need for increasing amounts of a drug to achieve the same effect, or a diminishing effect from the use of the same amount of a drug. Answer A is incorrect. Intoxication is a characteristic syndrome of maladaptive behavior or psychological changes that occurs with substance use, is drug-specific, and reverses when the
drug use is discontinued. Answer D is incorrect. Relapse involves restarting use of the drug after being abstinent for a while.
Discussion
The correct answer is E. Elevated GGT is considered to be the most sensitive indicator of alcohol intake and is often present along with elevation of the alanine and aspartate transaminases (ALT and AST). The classic AST:ALT ratio in active alcohol abusers is 2:1. Remember, however, that these laboratory findings are not specific for alcohol use. They can be induced by medications, etc. The other answers are incorrect. Patients with alcoholism typically have macrocytic anemia, elevated serum triglycerides, and hypoglycemia. Ferritin is often increased in active alcohol users.
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You have ordered liver function tests, but the results will not be available until the next day.
Which of the following medications would be indicated to prevent delirium tremens in a patient with hepatic impairment?
A) Alprazolam (Xanax).
B) Chlordiazepoxide (Librium).
C) Diazepam (Valium).
D) Oxazepam (Serax).
E) Clonazepam (Klonopin).
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Ans: D) Oxazepam (Serax).
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Discussion
The correct answer is D. Benzodiazepines that are metabolized by the cytochrome P450 system will build up in the presence of liver disease, so using those that are of intermediate half-lives and do not have active metabolites is essential. Only lorazepam, oxazepam, and temazepam meet these criteria, as all three are converted to their inactive glucuronide conjugates by cytosolic enzymes (rather than by the cytochrome P450 oxidative system) and then excreted. Answer B is incorrect. Although chlordiazepoxide is often used to prevent symptoms of alcohol withdrawal,
it is hepatically metabolized and has an exceptionally long half-life and, therefore, should be avoided in patients with liver problems. Alprazolam is too shortacting to use in this situation.
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