Substance Intoxication and Withdrawal — MCQs

10 questions

A patient presents to the emergency department with vomiting, diarrhea, lacrimation, abdominal cramps, and piloerection. The family members report a history of substance use for the past month. The clinical presentation is due to what?

In an accident case, after the arrival of medical team, all should be done in early management except;

A chronic alcoholic is brought to the emergency department with confusion, ataxia, and painful eye movements, including nystagmus. The 6th cranial nerve is also involved. What is the likely diagnosis?

A 16-year-old boy suffering from drug abuse presents with a cross-over of sensory perceptions, where sounds can be seen and colors can be heard. Which of the following is the most likely agent responsible for the drug abuse?

A patient is admitted with insomnia, agitation, diarrhea, dilated pupils, and sweating. What is the type of poisoning?

A 55-year-old chronic alcoholic male, presented with irrelevant talks, tremor and sweating. He had his last drink 3 days back. What is the probable diagnosis?

Delusion of persecution and formication occur together in

A 56-year-old man is brought to the emergency department by his wife because of memory loss and difficulty walking. She has noticed personality changes, truancy from work, and lack of personal care over the past 1 year. On examination, he appears unkempt, smells of urine, and is uncooperative. He cannot recall the date or season and gets angry when asked questions. His answers are often fabricated when checked with his wife. The blood pressure is 150/90 mm Hg, pulse 100/min, and he is diaphoretic and tremulous. His gait is wide-based, and motor strength and reflexes are normal. His ocular movements are normal, but there is nystagmus on lateral gaze. In the past, he has had multiple admissions for alcohol withdrawal. Which of the following is the most appropriate next step in management?

Visual hallucinations are most commonly seen in:

Q10

A patient stopped alcohol consumption for 3 days and presented with irritability, disorientation, paranoid delusions, agitation, visual hallucinations, and altered sensorium. What is the likely diagnosis in this case?

Substance Intoxication and Withdrawal Indian Medical PG Practice Questions and MCQs

Question 1: A patient presents to the emergency department with vomiting, diarrhea, lacrimation, abdominal cramps, and piloerection. The family members report a history of substance use for the past month. The clinical presentation is due to what?

A. opioid withdrawal (Correct Answer)
B. cocaine intoxication
C. cocaine withdrawal
D. opioid intoxication

Explanation: ***Opioid withdrawal*** - The constellation of **vomiting, diarrhea, lacrimation, abdominal cramps, and piloerection** (gooseflesh) are classic signs and symptoms of **opioid withdrawal**. - These symptoms reflect a **hyperactive sympathetic nervous system** as the body attempts to compensate for the absence of exogenous opioids. *Cocaine intoxication* - Cocaine intoxication typically presents with **euphoria, hyperactivity, tachycardia, hypertension, and paranoia**, which are not seen here. - It is characterized by **sympathomimetic effects**, leading to an agitated and stimulated state, rather than the distress seen in withdrawal. *Cocaine withdrawal* - Cocaine withdrawal typically manifests as **dysphoria, fatigue, increased appetite, psychomotor retardation or agitation, and vivid unpleasant dreams**, not the GI and autonomic symptoms described. - The primary symptoms are psychological and energetic, often described as a "crash" rather than the physical distress of opioid withdrawal. *Opioid intoxication* - Opioid intoxication primarily causes **CNS depression**, including **respiratory depression, meiosis (pinpoint pupils), sedation, and constipation**. - The patient's symptoms of vomiting, diarrhea, and lacrimation are contrary to the effects of opioid intoxication.

Question 2: In an accident case, after the arrival of medical team, all should be done in early management except;

A. Glasgow coma scale
B. Check BP (Correct Answer)
C. Stabilization of cervical vertebrae
D. Check Respiration

Explanation: ***Check BP*** - In the **immediate/early management** of trauma (primary survey), while circulation assessment is crucial, the **initial assessment of circulation** focuses on: - **Pulse rate and quality** (radial, carotid) - **Capillary refill time** - **Skin color and temperature** - **Active hemorrhage control** - **Formal blood pressure measurement** with a cuff, while important, is typically recorded during or after these rapid initial assessments, as it takes more time to obtain an accurate reading. - In the context of this question, among the four options listed, BP measurement is relatively less immediate compared to the other life-saving priorities (airway protection, breathing assessment, C-spine stabilization, and GCS). - **Note:** This is a nuanced distinction - BP is assessed during primary survey, but the other three options have more immediate life-threatening implications if not addressed. *Glasgow coma scale* - **GCS assessment** is part of the **"D" (Disability)** step in the ATLS primary survey. - It is performed early to assess neurological status and level of consciousness. - GCS <8 indicates need for **definitive airway protection** (intubation). - This is a critical early assessment that guides immediate management decisions. *Stabilization of cervical vertebrae* - **C-spine immobilization** is part of the **"A" (Airway)** step - "Airway with cervical spine protection." - It is performed **simultaneously** with airway assessment using a **rigid cervical collar**. - This is the **first priority** in trauma management to prevent secondary spinal cord injury. - All trauma patients should be assumed to have C-spine injury until proven otherwise. *Check Respiration* - **Respiratory assessment** is part of the **"B" (Breathing)** step in the ATLS primary survey. - This involves checking: - **Respiratory rate and pattern** - **Chest wall movement** - **Air entry bilaterally** - **Signs of tension pneumothorax or flail chest** - This is an immediate life-saving priority and must be assessed early.

Question 3: A chronic alcoholic is brought to the emergency department with confusion, ataxia, and painful eye movements, including nystagmus. The 6th cranial nerve is also involved. What is the likely diagnosis?

A. Wernicke's encephalopathy (Correct Answer)
B. Korsakoff psychosis
C. Delirium tremens
D. De Clerambault syndrome

Explanation: ***Wernicke's encephalopathy*** - This diagnosis aligns perfectly with the classic triad of **confusion, ataxia, and ophthalmoplegia** (manifested as painful eye movements, nystagmus, and 6th cranial nerve involvement) in the setting of chronic alcoholism [1], [2]. - It is caused by **thiamine (vitamin B1) deficiency**, common in chronic alcoholics due to malnutrition and impaired absorption [1]. *Korsakoff psychosis* - This condition is typically a **later complication** of Wernicke's encephalopathy, characterized by profound **anterograde and retrograde amnesia**, confabulation, and apathy [2]. - While an alcoholic patient might develop this, the immediate presentation with acute confusion, ataxia, and cranial nerve signs points to Wernicke's encephalopathy being the more acute and primary diagnosis in this scenario. *Delirium tremens* - This is a severe form of **alcohol withdrawal**, typically occurring 48-96 hours after the last drink, and is characterized by **global confusion, hallucinations (often visual), severe autonomic instability** (tachycardia, hypertension, fever, sweating), and seizures [3]. - While confusion is present, the specific neurological signs like ataxia and ophthalmoplegia are not typical of delirium tremens. *De Clerambault syndrome* - Also known as **erotomania**, this is a rare delusional disorder where an individual has a fixed, false belief that another person, usually of higher social status, is in love with them. - This is a **psychiatric disorder** with no relation to the neurological symptoms or alcohol-related complications described in the patient.

Question 4: A 16-year-old boy suffering from drug abuse presents with a cross-over of sensory perceptions, where sounds can be seen and colors can be heard. Which of the following is the most likely agent responsible for the drug abuse?

A. Cocaine, a stimulant that can cause heightened sensory perception and euphoria.
B. PCP, a dissociative drug that can cause hallucinations and altered sensory perceptions.
C. Marijuana, a psychoactive substance that can alter perception and cause mild hallucinations.
D. LSD, a hallucinogen known for causing synesthesia and intense sensory distortions. (Correct Answer)

Explanation: **LSD, a hallucinogen known for causing synesthesia and intense sensory distortions.** - **LSD (lysergic acid diethylamide)** is a classic **psychedelic** known for inducing profound alterations in perception, mood, and thought. - **Synesthesia**, the experience of a crossover of sensory perceptions (e.g., seeing sounds, hearing colors), is a hallmark effect of LSD, directly aligning with the patient's symptoms. *Cocaine, a stimulant that can cause heightened sensory perception and euphoria.* - **Cocaine** primarily acts as a stimulant, leading to increased alertness, euphoria, and sometimes paranoia or tactile hallucinations (e.g., **cocaine bugs**). - It does not typically cause synesthesia or the profound cross-sensory distortions described, which are more characteristic of hallucinogens. *PCP, a dissociative drug that can cause hallucinations and altered sensory perceptions.* - **PCP (phencyclidine)** is a dissociative anesthetic that can cause detachment, hallucinations, and altered perception of reality, often leading to bizarre or aggressive behavior. - While it causes altered sensory perceptions, the specific symptom of cross-sensory experiences like seeing sounds or hearing colors (**synesthesia**) is less characteristic of PCP and more strongly associated with classic hallucinogens. *Marijuana, a psychoactive substance that can alter perception and cause mild hallucinations.* - **Marijuana** (cannabis) can alter perception, enhance sensory experiences, and, at higher doses, produce mild hallucinations or distortions. - However, the intense and distinct cross-sensory phenomenon of synesthesia, where sounds are seen and colors heard, is rarely (if ever) the primary or most pronounced effect of marijuana use.

Question 5: A patient is admitted with insomnia, agitation, diarrhea, dilated pupils, and sweating. What is the type of poisoning?

A. Cannabis
B. Ecstasy
C. Heroin
D. Cocaine (Correct Answer)

Explanation: **Cocaine** - The symptoms of **insomnia, agitation, diarrhea, dilated pupils, and sweating** are classic manifestations of **sympathomimetic toxicity**, characteristic of cocaine poisoning. - Cocaine acts by **blocking the reuptake of norepinephrine, dopamine, and serotonin**, leading to excessive stimulation of the central and peripheral nervous systems. - This presentation represents a **pure sympathomimetic toxidrome** without additional complicating features, which is most classically associated with cocaine intoxication. *Heroin* - Heroin poisoning (opioid overdose) typically presents with **CNS depression**, including **respiratory depression**, **pinpoint pupils (miosis)**, and **constipation**, which are opposite to the symptoms described. - Patients are usually **sedated or comatose**, not agitated or insomniac. - This represents an **opioid toxidrome**, not a sympathomimetic one. *Cannabis* - Cannabis intoxication usually causes **conjunctival injection (red eyes)**, **tachycardia**, **dry mouth**, and **increased appetite**, often accompanied by euphoria or drowsiness. - While it can cause some anxiety/agitation in higher doses or naive users, it does **not cause mydriasis (dilated pupils)** or the severe physical stimulation seen here. - Cannabis does not produce a sympathomimetic toxidrome. *Ecstasy* - Ecstasy (MDMA) is also a sympathomimetic and can cause similar symptoms including agitation, dilated pupils, and sweating. - However, MDMA intoxication is more characteristically associated with **severe hyperthermia**, **hyponatremia**, **bruxism (teeth grinding)**, **serotonin syndrome**, and **rhabdomyolysis** in severe cases. - While both are sympathomimetics, the presentation described represents a **classic pure sympathomimetic picture** most consistent with **cocaine**, which is the more common cause of this toxidrome in clinical practice.

Question 6: A 55-year-old chronic alcoholic male, presented with irrelevant talks, tremor and sweating. He had his last drink 3 days back. What is the probable diagnosis?

A. Delirium tremens (Correct Answer)
B. Korsakoff psychosis
C. Post-Acute withdrawal syndrome
D. Discontinuation syndrome

Explanation: ***Delirium tremens*** - The presentation of **irrelevant talks**, **tremor**, and **sweating** in a chronic alcoholic who stopped drinking 3 days prior is highly characteristic of **delirium tremens**. - **Delirium tremens** is a severe form of acute **alcohol withdrawal**, typically occurring 2-4 days after the last drink, and involves extreme agitation, disorientation, hallucinations, and autonomic hyperactivity. *Korsakoff psychosis* - **Korsakoff psychosis** is a chronic neuropsychiatric syndrome associated with **thiamine deficiency**, often seen in chronic alcoholics. - It primarily presents with severe **anterograde and retrograde amnesia**, **confabulation**, and **apathy**, rather than acute, fluctuating consciousness and autonomic instability seen in delirium tremens. *Post-Acute withdrawal syndrome* - **Post-Acute Withdrawal Syndrome (PAWS)** involves persistent, milder symptoms that can last weeks or months after acute withdrawal. - Symptoms are generally less severe and acute than described, often including mood swings, anxiety, sleep disturbances, and cognitive impairment, not the acute delirium and autonomic overactivity presented. *Discontinuation syndrome* - **Discontinuation syndrome** refers to a cluster of symptoms that can occur after stopping or reducing certain medications, particularly antidepressants. - It is not directly related to alcohol withdrawal and typically presents with symptoms like dizziness, nausea, sensory disturbances, and flu-like symptoms.

Question 7: Delusion of persecution and formication occur together in

A. LSD
B. Cocaine (Correct Answer)
C. Amphetamine
D. Cannabis

Explanation: ***Cocaine*** - **Chronic cocaine abuse** can lead to **paranoid delusions** (delusions of persecution) and tactile hallucinations such as **formication** (sensation of insects crawling under the skin, called "**cocaine bugs**"). - These symptoms occur together in **cocaine-induced psychosis**, which can mimic **paranoid schizophrenia**. - The combination of **paranoid delusions with formication** is a classical presentation of **stimulant psychosis**, seen with cocaine. *Amphetamine* - **Amphetamine/methamphetamine abuse** can also cause **psychotic symptoms** including paranoia, delusions of persecution, and formication ("**meth mites**"). - While both cocaine and amphetamine can cause this combination, **cocaine** is the **traditional answer** in medical examinations for this specific combination of symptoms. - Clinically, amphetamine-induced formication is increasingly recognized. *LSD* - **Lysergic acid diethylamide (LSD)** primarily causes **visual hallucinations**, altered perceptions, and synesthesia. - While LSD can induce paranoia and anxiety, **delusions of persecution** and **formication** are not typical features. - LSD effects are more perceptual distortions than true psychotic symptoms. *Cannabis* - **Cannabis use** can sometimes induce **acute psychotic episodes** in vulnerable individuals, particularly with high-potency preparations. - Cannabis effects include **anxiety**, **paranoia**, and **depersonalization**. - **Formication** and prominent **delusions of persecution** are not characteristic of cannabis intoxication.

Question 8: A 56-year-old man is brought to the emergency department by his wife because of memory loss and difficulty walking. She has noticed personality changes, truancy from work, and lack of personal care over the past 1 year. On examination, he appears unkempt, smells of urine, and is uncooperative. He cannot recall the date or season and gets angry when asked questions. His answers are often fabricated when checked with his wife. The blood pressure is 150/90 mm Hg, pulse 100/min, and he is diaphoretic and tremulous. His gait is wide-based, and motor strength and reflexes are normal. His ocular movements are normal, but there is nystagmus on lateral gaze. In the past, he has had multiple admissions for alcohol withdrawal. Which of the following is the most appropriate next step in management?

A. Calcium administration
B. Prophylactic carbamazepine administration
C. Prophylactic phenytoin administration
D. Prophylactic diazepam administration (Correct Answer)

Explanation: ***Prophylactic diazepam administration*** - The patient presents with symptoms highly suggestive of **Wernicke-Korsakoff syndrome** (memory loss, ataxia, nystagmus) superimposed on chronic alcohol abuse with a history of alcohol withdrawal, indicating a high risk for further withdrawal seizures or delirium tremens [1], [3]. - **Benzodiazepines** like diazepam are the cornerstone of treatment for alcohol withdrawal syndrome due to their anxiolytic, anticonvulsant, and sedative properties, preventing progression to more severe withdrawal manifestations [2]. *Prophylactic phenytoin administration* - **Phenytoin** is generally not recommended for the prevention or treatment of alcohol withdrawal seizures unless there is an underlying seizure disorder unrelated to alcohol. - Its efficacy in preventing recurrent alcohol withdrawal seizures is limited compared to benzodiazepines. *Prophylactic carbamazepine administration* - While **carbamazepine** can be used in some cases of alcohol withdrawal, particularly to reduce seizure risk and improve sleep, it is not considered first-line for acute prophylaxis against severe withdrawal or delirium tremens, especially in a patient with active tremulousness and autonomic hyperactivity. - Benzodiazepines offer a broader spectrum of action against the diverse symptoms of alcohol withdrawal. *Calcium administration* - There is no indication that the patient has a **calcium deficiency** or hypocalcemia related to alcohol withdrawal symptoms. - Calcium administration would not address the underlying neurochemical imbalances associated with acute alcohol withdrawal or the progression to Wernicke-Korsakoff syndrome.

Question 9: Visual hallucinations are most commonly seen in:

A. OCD
B. Delusional syndrome
C. Delirium (Correct Answer)
D. Mania

Explanation: ***Delirium*** - **Visual hallucinations** are a hallmark symptom of **delirium**, often described as vivid and fluctuating. - Delirium presents with acute onset of **waxing and waning consciousness**, attention deficits, and cognitive impairment. *OCD* - **Obsessive-compulsive disorder** (OCD) is characterized by recurrent, intrusive thoughts (**obsessions**) and repetitive behaviors (**compulsions**). - It does not typically involve hallucinations; rather, individuals are usually aware of the irrationality of their obsessions and compulsions. *Delusional syndrome* - **Delusional disorders** primarily involve fixed, false beliefs (**delusions**) that are not bizarre and are not accompanied by prominent hallucinations. - While hallucinations can occur, they are generally not the most prominent or characteristic feature, unlike in delirium or psychotic disorders. *Mania* - **Mania**, a mood disorder, is characterized by an elevated, expansive, or irritable mood, increased activity, racing thoughts, and decreased need for sleep. - While psychotic features such as delusions (often grandiose) can occur in severe mania, **visual hallucinations** are less common than in delirium and audio hallucinations are more likely if present.

Question 10: A patient stopped alcohol consumption for 3 days and presented with irritability, disorientation, paranoid delusions, agitation, visual hallucinations, and altered sensorium. What is the likely diagnosis in this case?

A. Wernicke's encephalopathy
B. Alcohol withdrawal delirium (Correct Answer)
C. Korsakoff's psychosis
D. Alcohol intoxication

Explanation: ***Alcohol withdrawal delirium*** - The combination of **irritability, disorientation, paranoid delusions, agitation, visual hallucinations, and altered sensorium** developing 3 days after cessation of alcohol is classic for **delirium tremens**, the most severe form of alcohol withdrawal. - This condition is a medical emergency that can lead to seizures, cardiovascular collapse, and death if not treated promptly. *Wernicke's encephalopathy* - Characterized by the triad of **ataxia, ophthalmoplegia, and confusion**, which is due to **thiamine deficiency** and is not fully consistent with the patient's presentation. - While it can occur in chronic alcoholics, the rapid onset of severe agitation, hallucinations, and paranoia points more towards active withdrawal. *Korsakoff's psychosis* - This is a chronic neuropsychiatric syndrome that typically follows untreated Wernicke's encephalopathy, characterized by severe **anterograde and retrograde amnesia** and **confabulation**. - It does not present with the acute delirium, agitation, and prominent hallucinations described. *Alcohol intoxication* - This occurs when a person has recently consumed a large amount of alcohol, leading to symptoms like **slurred speech, impaired coordination, mood changes, and reduced inhibition**. - The patient's symptoms are occurring *after* stopping alcohol consumption for 3 days, indicating withdrawal, not active intoxication.

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