Alcohol/Drug Abuse

They may determine the presence of alcohol and drug dependence better than longer screening tools, according to a new study.

Dramatically elevated liver enzyme elevations in this man with alcoholic cirrhosis and clouded sensorium suggest a hepatocellular rather than an obstructive process.

the dramatic elevation of aminotransferases may be the result of medication toxicity, acute viral hepatitis, or ischemic injury to the liver. Your assessment?

A 65-year-old woman with a history of alcohol abuse, hospitalized because of acute pancreatitis, had had petechial hemorrhages on her legs for the past 3 months.

Forty-eight hours ago, a 39-year-old man presented to the emergency department with emesis and severe upper abdominal pain of semi-acute onset, which radiated slightly to the back.

An agitated and confused 51-year-old man is brought to the emergency departmentby his family and friends. Recently, he had been drinking heavilyand smoking cocaine. He stopped using alcohol and cocaine 2 days earlier,after he began to vomit.

A 45-year-old man presents with a 1- to2-week history of low-grade fever and nonproductivecough. He has a long history of cigarette and alcoholabuse. The office nurse expresses her concern about thepatients cyanotic nail beds and requests your immediateevaluation.

A 34-year-old man has had bilateralknee pain for the past 16 months andbilateral hip pain for the past 8 months.The pain is exacerbated by running, byweight bearing, and recently even by sittingfor extended periods. Moving froma sitting to a standing position is especiallydifficult. A week earlier, he visitedan urgent care center and was given naproxen and a 7-day course of prednisone,but neither medication alleviatedthe pain; in fact, he now feels worse.

A 49-year-old man complains of sharp pain in the medial left ankle that begansuddenly 3 nights earlier, waking him up. That night he also felt feverish anddiaphoretic, but those symptoms have subsided. The pain is present whenhe moves the ankle or when a shoe compresses the area. No other joints areinvolved. He denies trauma to the ankle or foot.

A 36-year-old man presents with a 10-day history of progressive dyspnea anddiscomfort on the left side of his chest.Three weeks earlier, he was dischargedfrom the hospital after a 2-week stayfor acute pancreatitis. He has a historyof long-term alcohol abuse and recurrentpancreatitis.

A 59-year-old woman complainsof progressively worsening bloatingand right upper quadrant pain thatbegan 1 day earlier. She denies feverand trauma. Her medical history includescholecystectomy for cholelithiasisand several emergency departmentvisits for treatment of woundssustained in falls. She has a history ofalcohol abuse, for which she now receivescounseling. However, she admitsthat she occasionally has boutsof heavy drinking.

Acamprosate calcium (Campral)from Lipha Pharmaceuticals, Inc,has been approved by the FDAfor the treatment of alcohol-dependentpersons who wish to remain alcohol-free after they have stoppeddrinking. Although its mechanismof action is not fully understood,this drug was shown to be more effectivethan placebo in maintainingabstinence. Acamprosate is nonaddictiveand has been shown to bewell tolerated in clinical trials. Themost common adverse effects areheadache, diarrhea, flatulence, andnausea.

A 68-year-old man with severe emphysema complains ofchest pain that began that morning. He has also had intermittentdiarrhea and occasional blood in his stool for thepast 2 weeks.

A 52-year-old woman is hospitalized because she has had jaundice, anorexia,and occasional nausea and vomiting for about 2 weeks. She has also had moderatepain in the epigastrium and right upper quadrant, but it has not been severeenough to require analgesics. She denies hematemesis and hematochezia.

A 53-year-old man complains ofdyspnea and a cough that has progressivelyworsened over the pastweek. He denies recent trauma.

A 64-year-old woman presentsto the emergency department withworsening crampy abdominal painthat began the night before. Afterthe pain started, she had a bowelmovement containing a significantamount of blood; since then she hashad episodes of diarrhea. She hadbeen previously healthy, denies traumaand fever, and knows no one withsimilar symptoms. She reports norecent enema, endoscopy, or otherabdominal procedure.

A 13-year-old boy complains ofpain in his right hip. The pain began3 days earlier after he was tackledseveral times while playing footballwith his friends. He was able to walkhome. The pain has increased sincethat time. Although the patient is stillable to walk, he now has a limp andfavors his left leg. The patient isotherwise healthy and has no significantmedical history.

A39-year-old man is brought to theemergency department (ED)after his car struck a tree. He experienceda transient loss of consciousnesswith a 3-minute episode of retrogradeamnesia at the scene of the accident,despite wearing a seat belt andshoulder harness. He was disorientedto date and place.

An 84-year-old woman presents with a 3-year history of slowly progressivememory impairment accompanied by functional decline. Thepatient lives alone but has been receiving an increasing amount of support from her 2 daughters,who accompany her to the appointment. The daughters first noticed that their mother was havingtrouble driving. About a year ago, she started forgetting family recipes. She also left food cookingon the stove unattended and burned several pans. Currently, the daughters are providing mealsand transportation, assisting with housework, and doing their mother’s laundry. They have becomeincreasingly alarmed because she takes her medications only sporadically, despite the factthat they fill her pillboxes and call her regularly with reminders. Their chief concern is whether itis safe for their mother to continue to live alone.

Alopecia was noted on the right anterior scalp of a 53-year-old man who had been hospitalized for jaundice of 2 weeks' duration. The hairs in the affected area were broken off at various lengths (A). The patient, who was left-handed, repeatedly pulled individual hairs on his head; it was suspected that he occasionally swallowed them.He had a history of heavy alcohol consumption and end-stage liver disease.

Alopecia was noted on the right anterior scalp of a 53-year-old man who had been hospitalized for jaundice of 2 weeks' duration. The hairs in the affected area were broken off at various lengths.

Patients with psychiatric disordersoften present a diagnostic challenge-even for psychiatrists. Their demeanormay not readily reveal the nature orseverity of the problem. Nevertheless,there are clues that can help you sortthrough the differential and arrive atthe correct diagnosis.

Anemia is usually detected as an incidentalfinding on a screening completeblood cell (CBC) count. Occasionally,a patient presents with symptoms andsigns that strongly suggest anemia,and a CBC count is ordered. In eithersetting, the next step is to determinethe cause of the anemia.

You routinely order laboratory screeningpanels, including serum liver enzymemeasurements, for nearly everypatient who has a complete physicalexamination or who is seen for any ofa host of other complaints. If you findabnormal liver enzyme levels, your familiaritywith the common causes andthe settings in which they occur mayenable you to avoid costly diagnosticstudies or biopsy.

A 45-year-old man comes to see you for a routine physical.He has no complaints and no significant medical history.However, while questioning him you discover that he usedintravenous heroin until about 10 years ago-and sometimesshared needles. He also drank 6 or more beers a day for about 20 years, a practicehe stopped at the same time that he quit using illicit drugs. He has multiple tattoos,which were done at commercial parlors. He is married but has no children. His wife hasno history of hepatitis. Physical examination is unremarkable.