Master the board step 3

Psychiatry
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Look for secondary effects of alcohol use (but not for diagnosis): elevated
GGTP, AST, ALT, and LDH.
··
If there’s suggestion of IV drug use (e.g., track marks), order HIV, hepatitis
B, hepatitis C, and PPD (for tuberculosis).
Management
If the question asks for the most effective management of alcohol abuse or
prevention of relapse, the correct answer is Alcoholics Anonymous (AA).
Basic Science Correlate
Disulfiram inhibits the enzyme acetaldehyde dehydrogenase, leading to a
rise in acetaldehyde. Acetaldehyde is responsible for the vomiting, headache,
tachycardia, and sweating.
Acute Outpatient Management
of Alcohol Dependence
1) Prevent further ETOH intake
2) Prevent individual from driving
a car, operating machinery
3) Sedate patient if he or she
becomes agitated
4) Transfer to inpatient
Acute Inpatient Management
Pearls
1) Look for withdrawal symptoms
2) Prevent Wernicke-Korsakoff (ataxia,
nystagmus, ophthalmoplegia,
amnesia): Give IV or IM thiamine
and magnesium ASAP; also give
B12 and folate
3) Benzodiazepine of choice is
chlordiazepoxide or diazepam
4) Choose short-acting
benzodiazepam only if the
question describes patient with
severe liver disease (prevent toxic
metabolites)—lorazepam or
oxazepam
5) Do not give seizure prophylaxis;
repeated seizures should be treated
with diazepam
6) Haldol is never the answer (reduces
seizure threshold)
Chronic Maintenance
Management
1) Refer to inpatient rehabilitation
or outpatient group therapy
(e.g., AA)
2) Never give drug therapy
without group psychotherapy
3) Naloxone and acamprosate
decrease relapse rate only when
given with psychotherapy
4) Disulfiram has poor compliance
and hasn’t been shown to be
effective
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