A 52-year-old man with alcohol use disorder has confusion, ataxia, and nystagmus in the ED. Glucose is 52 mg/dL. Which next step is best?
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USMLE Step 2 Quiz
Practice Substance Use And Addiction in USMLE Step 2 with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.
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A 52-year-old man with alcohol use disorder has confusion, ataxia, and nystagmus in the ED. Glucose is 52 mg/dL. Which next step is best?
This quiz focuses on Substance Use And Addiction, giving you a quick way to practice the rules, question types, and explanations that matter most for USMLE Step 2.
Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.
A 52-year-old man with alcohol use disorder has confusion, ataxia, and nystagmus in the ED. Glucose is 52 mg/dL. Which next step is best?
Explanation: This question tests medical students' understanding of substance use and addiction management in a clinical context, focusing on psychiatric principles. Substance use disorders require a nuanced understanding of withdrawal symptoms, intoxication effects, and management strategies, emphasizing evidence-based practice. In this vignette, the patient's presentation and history provide critical clues for diagnosis and management, such as confusion, ataxia, nystagmus, and hypoglycemia in alcohol use disorder. The correct answer, choice A, is the best clinical decision because IV thiamine before dextrose prevents Wernicke encephalopathy exacerbation per neurology guidelines. A common distractor, choice B, is incorrect because giving dextrose first without thiamine can precipitate acute Wernicke syndrome in thiamine-deficient patients. Effective strategies include familiarizing oneself with withdrawal protocols and staying updated on guidelines. Practicing case scenarios and understanding the nuances of dual diagnosis can improve decision-making skills.
A 44-year-old woman takes high-dose alprazolam daily and stops abruptly 3 days ago. She has tremor, insomnia, and a seizure. Which medication is best?
Explanation: This question tests medical students' understanding of substance use and addiction management in a clinical context, focusing on psychiatric principles. Substance use disorders require a nuanced understanding of withdrawal symptoms, intoxication effects, and management strategies, emphasizing evidence-based practice. In this vignette, the patient's presentation and history provide critical clues for diagnosis and management, such as tremor, insomnia, and seizure after abrupt alprazolam cessation. The correct answer, choice A, is the best clinical decision because starting a long-acting benzodiazepine with gradual taper prevents severe withdrawal per psychiatric guidelines. A common distractor, choice D, is incorrect because flumazenil can precipitate seizures in benzodiazepine-dependent patients. Effective strategies include familiarizing oneself with withdrawal protocols and staying updated on guidelines. Practicing case scenarios and understanding the nuances of dual diagnosis can improve decision-making skills.
A 34-year-old man with a history of chronic back pain presents to his primary care physician. He was initially prescribed oxycodone after a motor vehicle accident two years ago. For the past year, he has found himself taking higher doses than prescribed to achieve the same pain relief. He frequently runs out of his prescription early and has sought prescriptions from multiple providers. He has tried to cut down on his use without success and reports spending a significant amount of his day thinking about, obtaining, or using the medication. This has caused him to miss several days of work. He reports intense cravings when he is not using the medication.
Which of the following is the most likely diagnosis?
Explanation: This patient meets multiple DSM-5 criteria for a severe opioid use disorder, including tolerance (needing higher doses), loss of control (taking more than intended, unsuccessful attempts to cut down), spending a great deal of time on the substance, and functional impairment (missing work). The presence of 6 or more criteria indicates a severe disorder. While he may have underlying pain, his behaviors clearly constitute a substance use disorder. Somatic symptom disorder involves distressing physical symptoms with excessive thoughts/feelings about them, which is not the primary issue. Malingering involves faking symptoms for external gain, which is not described here.
A 35-year-old man presents with a two-month history of depressed mood, anhedonia, fatigue, and feelings of worthlessness. He also reports drinking a pint of vodka daily for the past year, which he states is to 'help him cope.' He has no prior history of mood episodes when he was not drinking heavily.
What is the most important step to distinguish between a primary depressive disorder and a substance-induced depressive disorder?
Explanation: Heavy alcohol use can cause depressive symptoms that are indistinguishable from major depressive disorder. The most crucial diagnostic step is to determine if the mood symptoms persist during a period of sobriety. If the depressive symptoms resolve within about 4 weeks of abstinence, a diagnosis of substance-induced depressive disorder is made. If they persist, a primary depressive disorder is more likely. Starting an SSRI or obtaining more history is premature until the effect of the substance is removed.
A 45-year-old man reports to his physician that he is concerned about his drinking. He states he drinks a six-pack of beer every evening. He has tried to cut down several times but has been unable to. His wife has threatened to leave him because of his drinking. Last year, he was arrested for driving under the influence. Despite these issues, he continues to drink daily. He denies tolerance or withdrawal symptoms.
Based on the DSM-5 criteria, what is the most appropriate severity specifier for this patient's alcohol use disorder?
Explanation: The patient meets the following four criteria for alcohol use disorder: 1) unsuccessful efforts to cut down/control use; 2) continued use despite persistent interpersonal problems (wife's threats); 3) recurrent use in situations in which it is physically hazardous (DUI); and 4) craving (implied by inability to cut down). According to DSM-5, the presence of 4-5 criteria indicates a moderate substance use disorder. Mild is 2-3 criteria, and severe is 6 or more criteria. He is not in remission as he is actively using.
A 23-year-old graduate student who smoked cannabis daily for the past 5 years quits abruptly due to a new job that requires drug testing. Four days later, he presents to his primary care physician complaining of being 'on edge' and 'in a bad mood.' He reports difficulty falling asleep, strange dreams, decreased appetite, and headaches.
The patient's symptoms are most consistent with which of the following?
Explanation: This patient is experiencing a classic cannabis withdrawal syndrome. Symptoms typically begin within a week of cessation after prolonged, heavy use and include irritability, anger, anxiety, insomnia, disturbing dreams, decreased appetite, and physical symptoms like headaches or sweating. The clear temporal relationship to quitting cannabis makes this the most likely diagnosis. While he has symptoms of anxiety and depression, they are better explained by the withdrawal syndrome.
A 33-year-old woman who has been using cocaine daily for the past year abruptly stops. She presents to her physician 4 days later complaining of an inability to feel pleasure, overwhelming fatigue, and hypersomnia. She also reports intense cravings for cocaine. Her mood is dysphoric, but she denies suicidal ideation.
Which of the following is the most appropriate management for this patient's condition?
Explanation: This patient is experiencing stimulant withdrawal syndrome, often called 'the crash'. It is characterized by dysphoria, anhedonia, fatigue, and intense cravings. The withdrawal is not medically dangerous, and there is no FDA-approved pharmacotherapy. The mainstay of treatment is supportive care, including counseling, psychoeducation, and monitoring of mood. While medications like bupropion and modafinil have been studied, they have not shown consistent efficacy and are not standard of care. Benzodiazepines are not indicated.
A 24-year-old man is brought to the emergency department from a nightclub. He is agitated, diaphoretic, and paranoid. His temperature is 39.0°C (102.2°F), blood pressure is 185/115 mm Hg, and pulse is 140/min. His pupils are 8 mm and reactive. An ECG reveals sinus tachycardia with no ischemic changes. He admits to snorting cocaine.
Which of the following is the most appropriate initial medication for this patient's agitation and hypertension?
Explanation: The management of sympathomimetic toxicity from cocaine focuses on controlling agitation, hypertension, and tachycardia. Benzodiazepines, like lorazepam, are the first-line treatment. They reduce central sympathetic outflow, thereby controlling agitation and lowering heart rate and blood pressure. Beta-blockers (even non-selective ones like labetalol) should be avoided due to the risk of unopposed alpha-adrenergic stimulation, which can worsen hypertension and coronary vasospasm. Haloperidol can be used for psychosis but does not address the underlying sympathomimetic storm as well as benzodiazepines. Phentolamine is a pure alpha-blocker used for refractory hypertension.
A 52-year-old woman is in a residential treatment program for a severe alcohol use disorder. She is working with a therapist on strategies to prevent relapse upon her discharge. She is worried about attending a family wedding next month where alcohol will be served.
Which of the following is the most effective cognitive-behavioral strategy to discuss with this patient?
Explanation: A cornerstone of relapse prevention, a form of cognitive-behavioral therapy, is to identify high-risk situations (triggers) and develop proactive coping strategies. This could include planning what to say if offered a drink, having a non-alcoholic beverage in hand, identifying a support person to call, and having an exit strategy. Simply avoiding all triggers is often not practical and does not build coping skills. The other options are either not therapeutic or unrealistic.
A 52-year-old woman has been taking lorazepam 2 mg twice daily for anxiety for 10 years. She abruptly stops the medication. Three days later, she presents with severe anxiety, insomnia, hand tremors, and diaphoresis. She also reports perceptual disturbances, stating that lights seem overly bright and sounds are louder than usual.
Which of the following is the most serious potential complication of her current condition?
Explanation: This patient is experiencing acute benzodiazepine withdrawal. Abrupt cessation of long-term benzodiazepine use leads to a state of CNS hyperexcitability. While autonomic instability and perceptual disturbances are common, the most dangerous and life-threatening complication is the development of generalized tonic-clonic seizures. Management involves reinstating a long-acting benzodiazepine and initiating a slow taper.
A 25-year-old woman with a history of anxiety is brought to the emergency department after ingesting an entire bottle of her prescribed alprazolam. She is profoundly somnolent and difficult to arouse. Her respiratory rate is 10/min and her oxygen saturation is 92% on room air. There is no suspicion of co-ingestion with other substances.
Which of the following is the most appropriate initial management step?
Explanation: The management of an isolated benzodiazepine overdose is primarily supportive care. The most critical aspect is ensuring airway patency and adequate ventilation and oxygenation. Most patients recover fully with this approach. Flumazenil, a benzodiazepine antagonist, is generally not recommended because it can precipitate seizures in patients with chronic benzodiazepine use or in cases of unknown co-ingestions (e.g., tricyclic antidepressants), and the risks often outweigh the benefits. Intubation is reserved for patients who cannot protect their airway or have severe respiratory failure, which is not yet indicated here. Activated charcoal is only useful very soon after ingestion and requires a protected airway.
A 31-year-old man has fever, diaphoresis, tremor, hyperreflexia, and clonus after taking linezolid with sertraline. Which diagnosis is most likely?
Explanation: This question tests medical students' understanding of substance use and addiction management in a clinical context, focusing on psychiatric principles. Substance use disorders require a nuanced understanding of withdrawal symptoms, intoxication effects, and management strategies, emphasizing evidence-based practice. In this vignette, the patient's presentation and history provide critical clues for diagnosis and management, such as fever, diaphoresis, tremor, hyperreflexia, and clonus after linezolid with sertraline. The correct answer, choice A, is the best clinical decision because serotonin syndrome arises from MAOI-SSRI interaction per pharmacology guidelines. A common distractor, choice B, is incorrect because neuroleptic malignant syndrome involves rigidity and antipsychotic use, not this combination. Effective strategies include familiarizing oneself with withdrawal protocols and staying updated on guidelines. Practicing case scenarios and understanding the nuances of dual diagnosis can improve decision-making skills.
A 42-year-old woman has been sober for one month after completing a medical detoxification program for severe alcohol use disorder. She is motivated to maintain abstinence and asks about medications that can help reduce her cravings. She has no significant medical history, and her liver function tests are normal. She denies any current use of opioids or other substances.
Which of the following medications is most appropriate to initiate to help this patient maintain abstinence?
Explanation: Naltrexone is an opioid antagonist that is a first-line, FDA-approved treatment for alcohol use disorder. It helps reduce cravings and the rewarding effects of alcohol, thereby decreasing the risk of relapse. Disulfiram is a second-line agent that works by causing an aversive reaction to alcohol and is less effective due to adherence issues. Chlordiazepoxide is a benzodiazepine used for managing acute alcohol withdrawal, not for long-term maintenance. Clonidine is used to manage autonomic symptoms of withdrawal.
A 22-year-old man is brought to the emergency department after being found unresponsive by his roommate. On examination, his respiratory rate is 6/min and shallow. His pupils are 1 mm and reactive. Pulse oximetry shows an oxygen saturation of 85% on room air. There are track marks on his arms.
In addition to airway support and supplemental oxygen, which of the following is the most appropriate immediate intervention?
Explanation: The clinical presentation of respiratory depression, pinpoint pupils (miosis), and unresponsiveness in a patient with evidence of intravenous drug use is classic for an opioid overdose. Naloxone is a competitive opioid antagonist and is the specific antidote that can rapidly reverse the life-threatening respiratory depression. Flumazenil is a benzodiazepine antagonist. A head CT would be considered if there was suspicion of trauma, but overdose is far more likely. Gastric lavage is not indicated for intravenous drug use and is generally not recommended for toxic ingestions.
A 31-year-old man with a history of intravenous heroin use presents to the emergency department with a two-week history of fever, fatigue, and night sweats. On physical examination, his temperature is 38.8°C (101.8°F). A new, blowing, holosystolic murmur is heard best at the left lower sternal border, and it intensifies with inspiration. Several tender nodules are noted on his fingertips.
These findings are most suggestive of which of the following complications of his substance use?
Explanation: The classic triad of fever, a new heart murmur, and a history of intravenous drug use is highly suggestive of infective endocarditis. In IV drug users, the tricuspid valve is most commonly affected due to the introduction of bacteria into the venous system. The murmur of tricuspid regurgitation is typically a holosystolic murmur at the left lower sternal border that increases with inspiration (Carvallo's sign). The tender nodules (Osler nodes) are an immunologic phenomenon associated with endocarditis.
A 20-year-old college student is brought to the student health clinic by his roommate. The roommate reports that for the past week, the student has been accusing him of being a government spy and has been barricading the door to their room. The student has no prior psychiatric history, but his roommate notes he has been using large amounts of amphetamines to study for exams. On examination, the student is fearful and has persecutory delusions but is oriented.
Which of the following is the most likely diagnosis?
Explanation: The development of psychotic symptoms (delusions) in the context of recent, heavy substance use (amphetamines) makes a substance-induced psychotic disorder the most likely diagnosis. The temporal relationship between substance use and the onset of symptoms is key. Schizophrenia and schizophreniform disorder are less likely given the clear substance use trigger and lack of prior psychiatric history. A brief psychotic disorder is a diagnosis of exclusion and is less likely when a substance is the probable cause.
A 29-year-old construction worker with opioid use disorder presents to a primary care clinic seeking treatment. He wants to stop using heroin. He has a stable job and housing and is looking for a treatment that can be managed on an outpatient basis without daily clinic visits. He is not currently in withdrawal.
Which of the following is the most appropriate medication-assisted treatment to offer this patient?
Explanation: Buprenorphine is a partial opioid agonist that can be prescribed from a certified physician's office, making it ideal for stable patients who do not require the structure of a daily methadone clinic. It effectively reduces cravings and prevents withdrawal. It is typically combined with naloxone to deter intravenous misuse. Methadone requires daily visits to a licensed opioid treatment program. Naltrexone requires a period of complete opioid abstinence before initiation, or it will precipitate withdrawal. Clonidine only treats the autonomic symptoms of withdrawal and is not a maintenance therapy.
A 65-year-old man with a history of homelessness and chronic, severe alcohol use is brought to the emergency department due to confusion. On examination, he is disoriented and lethargic. He has bilateral horizontal nystagmus on lateral gaze and a wide-based, unsteady gait. Intravenous access is obtained.
Which of the following should be administered before any glucose-containing fluids?
Explanation: The patient's presentation with the classic triad of encephalopathy (confusion), oculomotor dysfunction (nystagmus), and gait ataxia is highly suggestive of Wernicke encephalopathy, a condition caused by thiamine (vitamin B1) deficiency. In malnourished patients, particularly those with chronic alcoholism, administering glucose can precipitate or worsen Wernicke encephalopathy by rapidly depleting the body's limited thiamine reserves, as thiamine is a crucial cofactor in glucose metabolism. Therefore, thiamine must always be given before glucose.
A 26-year-old man with a known history of opioid use disorder presents for a follow-up visit. He is not currently interested in starting buprenorphine or methadone but expresses fear of a fatal overdose. He often uses drugs alone.
In addition to counseling on the dangers of his use and offering treatment, which of the following is the most appropriate harm reduction intervention for this patient?
Explanation: Harm reduction strategies aim to minimize the negative consequences of drug use for patients who are unable or unwilling to stop. Prescribing naloxone, an opioid antagonist, and teaching the patient (and his friends/family) how to use it in case of an overdose is a critical, evidence-based intervention that can prevent death. Insisting on a specific treatment (detox) when the patient is not ready is unlikely to be successful. While switching routes of administration may reduce some risks (e.g., infection), it does not prevent overdose. Urine screens are for monitoring, not harm reduction.
A 60-year-old man with alcohol-related cirrhosis (Child-Pugh class C) is discharged from the hospital after an episode of hepatic encephalopathy. He is committed to maintaining sobriety and asks about medications to prevent relapse. His laboratory results show an INR of 1.8, total bilirubin of 4.1 mg/dL, and albumin of 2.5 g/dL.
Which of the following medications is the safest option for relapse prevention in this patient?
Explanation: Acamprosate is primarily excreted by the kidneys and does not undergo hepatic metabolism, making it the safest first-line medication for alcohol use disorder in patients with severe liver disease or cirrhosis. Both naltrexone and disulfiram are metabolized by the liver and can be hepatotoxic, making them relatively or absolutely contraindicated in patients with decompensated cirrhosis. Topiramate is used off-label and also has hepatic metabolism.