Friday, February 4, 2011

Intern Report Answer 3.1


Resolution
The patient was seen as a medical code called for status epilepticus, likely secondary to alcohol withdrawal.  The seizures were eventually terminated with very high doses of benzodiazepines that resulted in the need for intubation for compromise of respiratory drive and questionable obstruction.  She was admitted to the Medical ICU for continuing care of severe alcohol withdrawal.
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Answers
Q1: (C)
Lorazepam is metabolized by the liver, and the half-life in patients with normal livers is 7-14 hours.  However, in patients with liver disease (like chronic hepatitis C), the metabolism of lorazepam is prolonged, resulting in the active agent remaining available in the circulation.  In the treatment of alcohol withdrawal, decreased metabolism rate is beneficial because GABA activity is extended, decreasing seizure activity longer.

Q2: (B)
Although acute dystonic and akinesthetic reactions secondary to butyrophenone administration are not common, they are very alarming to patients, staff, and family members and require prompt, appropriate treatment.  While each of these medications has been implemented in the treatment of dystonia, Diphenhydramine is the drug of choice for acute reactions and rapid treatment.  Diphenhydramine can be given IM, IV, or po, although initial treatment IM or IM is most effective for rapid resolution of symptoms.  The usual initial dose is 25 to 50 mg depending on the severity of symptoms.  Dosing can be repeated if symptoms re-appear, and patients and family members should be warned that symptoms may persist for up to one week – patients can take oral Diphenhydramine when symptoms develop and only need to seek medical care if the symptoms do not improve after administration.

Q3: (A)
Diarrhea, nausea, vomiting, and abdominal pain are common presenting symptoms in patients experiencing opioid withdrawal.  Although nausea and vomiting are also symptoms of alcohol withdrawal (and are scored on the CIWA-Ar), diarrhea and abdominal pain are not common in alcohol withdrawal, and should raise suspicion that some other process may be occurring in a patient that has abstained from alcohol for some time.  With regards to mental status, patients suffering from alcohol withdrawal often present with obvious disorientation; patients with psychiatric disorders are typically oriented to person, place, and time (although other aspects of their mental status will be incorrect).  Additionally, while both alcohol withdrawal and psychiatric disorders present with hallucinations, psychiatric hallucinations are classically auditory and alcohol hallucinations are classically visual.

Q4: (B)
According to the National Institute of Health, the number of drinks per day that exceeds a “safe” level in men under the age of 65 is 4 drinks per day / 14 drinks per week.  For women under 65, and anyone over 65, the limit is 3 drinks per day / seven drinks in one week.

Q5: (C)
Status epilepticus is defined as two or more sequential seizures without full recovery of consciousness between seizures or more than 30 minutes of continuous seizure activity. 

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