In the CAGE questionnaire for alcohol use, what does the letter E ask about?

A morning drink to steady the nerves

Emergency visits after drinking

Excess money spent on buying alcohol

A 31-year-old man on a methadone programme is brought to casualty unresponsive, with pinpoint pupils and a respiratory rate of 6/min, after taking extra doses. IV naloxone 0.4 mg wakes him within two minutes and he wants to leave. What is the next best step?

Observe and continue naloxone as needed for hours

Discharge him once he is fully awake and oriented

Give oral naltrexone and discharge him

Give IV flumazenil to prevent relapse

A 23-year-old woman at 14 weeks of pregnancy has had hyperemesis gravidarum for six weeks and has been on IV dextrose saline for ten days. She now has confusion, horizontal nystagmus, diplopia and an unsteady gait. Serum sodium is 136 mmol/L and glucose 98 mg/dL. What is the next best step?

IV thiamine in high doses at once

Substance use and withdrawal

16 NEET-PG practice questions on Substance use and withdrawal, part of Psychiatry. The first 16 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Easy
In the CAGE questionnaire for alcohol use, what does the letter E ask about?
1. AEpisodes of memory blackout
2. BEmergency visits after drinking
3. CA morning drink to steady the nerves
4. DExcess money spent on buying alcohol
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Answer: C · A morning drink to steady the nerves
CAGE asks four questions: feeling the need to Cut down, being Annoyed by criticism of drinking, feeling Guilty about drinking, and needing an Eye-opener drink in the morning. Two or more 'yes' answers suggest clinically significant alcohol use and call for fuller assessment. It is quick to use in OPDs and primary care. It screens for a problem but does not measure the amount drunk.
- A: Blackouts are not one of the four CAGE items.
- B: Emergency visits are not a CAGE item.
- D: Money spent is not a CAGE item.
Question 2 · Hard
A 55-year-old man with alcoholic cirrhosis (albumin 2.6 g/dL, INR 1.8) is admitted in alcohol withdrawal and had one seizure 20 hours after his last drink. The resident's plan: 1. Phenytoin to prevent further withdrawal seizures. 2. Lorazepam rather than chlordiazepoxide. 3. IV thiamine before glucose-containing fluids. 4. Benzodiazepine doses guided by CIWA-Ar scores. Which parts of the plan are correct?
1. A1, 3 and 4 only
2. B1, 2 and 3 only
3. C2 and 4 only
4. D2, 3 and 4 only
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Answer: D · 2, 3 and 4 only
Steps 2, 3 and 4 are correct. In liver failure lorazepam (or oxazepam) is preferred because it is only glucuronidated and has no active metabolites, whereas chlordiazepoxide and diazepam accumulate. Thiamine is given before glucose to prevent Wernicke encephalopathy, and symptom-triggered dosing by CIWA-Ar avoids over-sedation. Step 1 is wrong: phenytoin does not prevent alcohol withdrawal seizures, which respond to benzodiazepines.
- A: Includes phenytoin and omits lorazepam, which is preferred in cirrhosis.
- B: Includes phenytoin and omits CIWA-Ar symptom-triggered dosing.
- C: Omits thiamine before glucose, which prevents Wernicke encephalopathy.
Question 3 · Hard
A 31-year-old man on a methadone programme is brought to casualty unresponsive, with pinpoint pupils and a respiratory rate of 6/min, after taking extra doses. IV naloxone 0.4 mg wakes him within two minutes and he wants to leave. What is the next best step?
1. ADischarge him once he is fully awake and oriented
2. BObserve and continue naloxone as needed for hours
3. CGive oral naltrexone and discharge him
4. DGive IV flumazenil to prevent relapse
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Answer: B · Observe and continue naloxone as needed for hours
Naloxone acts for only about 30 to 90 minutes, whereas methadone has a long half-life, so respiratory depression often returns after naloxone wears off. He must be kept under observation with repeated boluses or a naloxone infusion titrated to breathing, for many hours. Discharge after a single dose risks death at home. Naltrexone would precipitate prolonged withdrawal in a methadone-dependent patient.
- A: Early discharge is dangerous: methadone outlasts naloxone and sedation recurs.
- C: Naltrexone precipitates prolonged withdrawal and is not an overdose treatment.
- D: Flumazenil reverses benzodiazepines, not opioids.
Question 4 · Hard
A 23-year-old woman at 14 weeks of pregnancy has had hyperemesis gravidarum for six weeks and has been on IV dextrose saline for ten days. She now has confusion, horizontal nystagmus, diplopia and an unsteady gait. Serum sodium is 136 mmol/L and glucose 98 mg/dL. What is the next best step?
1. AMRI brain before any treatment
2. BIV thiamine in high doses at once
3. CHypertonic saline infusion
4. DOral vitamin B complex tablets
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Answer: B · IV thiamine in high doses at once
Prolonged vomiting with glucose-containing fluids and no vitamin supplements can precipitate Wernicke encephalopathy, because glucose metabolism uses up the little thiamine left. Confusion, nystagmus with ophthalmoplegia and ataxia need immediate high-dose parenteral thiamine, without waiting for imaging. Thiamine should be given to every woman with prolonged hyperemesis before or with dextrose. Untreated, it risks permanent memory loss and fetal loss.
- A: MRI may show changes but treatment must not be delayed for it.
- C: Her sodium is normal; this is not hyponatraemia or osmotic demyelination.
- D: Oral absorption is unreliable with vomiting and too slow for an emergency.
Question 5 · Medium
A medical officer at a PHC screens a 38-year-old truck driver for alcohol problems. He answers yes to feeling he should cut down and to feeling guilty about his drinking. Consider these statements: 1. Two positive CAGE answers suggest clinically significant alcohol use. 2. AUDIT is a four-item questionnaire derived from CAGE. 3. CAGE estimates the quantity of alcohol drunk per week. 4. A raised GGT and MCV support chronic heavy drinking. Which statements are correct?
1. A1, 3 and 4 only
2. B1, 2 and 4 only
3. C1 and 4 only
4. D1 and 3 only
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Answer: C · 1 and 4 only
Statements 1 and 4 are correct. Two or more 'yes' answers on CAGE, as here, suggest a clinically significant problem that needs fuller assessment; raised GGT and macrocytosis are supportive markers of chronic heavy drinking. AUDIT is not derived from CAGE: it is a separate 10-item WHO tool covering consumption, dependence and harm. CAGE does not measure quantity, which is why AUDIT or a drinking history is used for that.
- A: Includes statement 3; CAGE does not estimate quantity.
- B: Includes statement 2; AUDIT is a separate 10-item WHO tool, not a four-item CAGE variant.
- D: Includes statement 3 and omits statement 4 about GGT and MCV.
Question 6 · Easy
A 48-year-old daily-wage worker who has drunk arrack heavily for 20 years is brought to casualty confused. He has nystagmus, bilateral lateral rectus palsy and a broad-based unsteady gait. Deficiency of which vitamin is responsible?
1. ANiacin
2. BCobalamin
3. CPyridoxine
4. DThiamine
Answer and explanation in LearnFree account
Question 7 · Medium
A 36-year-old man on disulfiram after alcohol detoxification drinks two pegs at a wedding. Within 20 minutes he has facial flushing, throbbing headache, vomiting, palpitations and a fall in blood pressure. Accumulation of which substance causes these symptoms?
1. AAcetaldehyde
2. BAcetic acid
3. CEthanol
4. DMethanol
Answer and explanation in LearnFree account
Question 8 · Medium
A 44-year-old man admitted with a fractured femur is calm on admission. On the third day he becomes disoriented, picks at the bedsheet, sees insects crawling on the wall, sweats profusely and has temperature 38.4 C, pulse 128/min and coarse tremor. His wife says he drinks daily. What is the most likely diagnosis?
1. AAlcoholic hallucinosis
2. BFat embolism syndrome
3. CWernicke encephalopathy
4. DDelirium tremens
Answer and explanation in LearnFree account
Question 9 · Medium
A 50-year-old man with chronic alcohol use is admitted with confusion and ataxia. Wernicke encephalopathy is suspected and thiamine is started. To confirm thiamine deficiency, the laboratory measures the activity of which red cell enzyme before and after adding thiamine pyrophosphate?
1. AAspartate aminotransferase
2. BGlutathione reductase
3. CTransketolase
4. DPyruvate kinase
Answer and explanation in LearnFree account
Question 10 · Medium
A 39-year-old autorickshaw driver cut down his heavy drinking two days ago. He is fully oriented and has no tremor, but he hears several men discussing him and threatening to beat him, and he has barricaded his room. Vitals are normal. What is the most likely diagnosis?
1. APathological jealousy
2. BAlcoholic hallucinosis
3. CDelirium tremens
4. DKorsakoff syndrome
Answer and explanation in LearnFree account
Question 11 · Medium
A 33-year-old man on opioid substitution is switched from buprenorphine alone to a sublingual tablet of buprenorphine combined with naloxone. Why is naloxone added?
1. ATo deter crushing and injecting the tablet
2. BTo reduce constipation from buprenorphine
3. CTo prolong the action of buprenorphine
4. DTo treat overdose if he drinks alcohol
Answer and explanation in LearnFree account
Question 12 · Medium
A 25-year-old man in a de-addiction centre in Amritsar is 18 hours from his last dose of heroin. He has yawning, watering eyes, running nose, dilated pupils, gooseflesh, abdominal cramps and diarrhoea. He refuses opioid substitution. Which drug best relieves his autonomic symptoms?
1. AClonidine
2. BNaloxone
3. CAtropine
4. DHaloperidol
Answer and explanation in LearnFree account
Question 13 · Easy
A 52-year-old man who drinks a litre of whisky a day is admitted for elective hernia surgery. Twelve hours after his last drink he becomes tremulous, sweaty and anxious, with pulse 112/min. Liver function is normal. Which drug is preferred to treat his withdrawal?
1. AHaloperidol
2. BDisulfiram
3. CChlordiazepoxide
4. DPhenytoin
Answer and explanation in LearnFree account
Question 14 · Medium
A 58-year-old man with 30 years of heavy drinking was treated for Wernicke encephalopathy last year. He is alert and attentive but cannot remember anything from a few minutes ago, and when asked what he did yesterday he describes a trip to the market that never happened. Damage to which structures most characteristically underlies this?
1. APrimary visual cortex
2. BCerebellar vermis alone
3. CMammillary bodies and medial thalamus
4. DCaudate nuclei and putamina on both sides
Answer and explanation in LearnFree account
Question 15 · Medium
A 29-year-old man who injects heroin is enrolled at an opioid substitution therapy centre. His first dose of sublingual buprenorphine is given four hours after his last injection. Within an hour he has severe sweating, cramps, vomiting and diarrhoea. What explains this reaction?
1. AA high-affinity partial agonist displacing a full agonist
2. BAn allergic reaction to buprenorphine
3. CRapid liver metabolism of buprenorphine
4. DA full agonist adding to residual heroin
Answer and explanation in LearnFree account
Question 16 · Medium
A 47-year-old man with alcohol dependence and compensated cirrhosis (bilirubin 2.1 mg/dL, ascites controlled) has completed detoxification and wants a drug to reduce craving. His creatinine is normal. Which drug is most suitable?
1. ADisulfiram
2. BChlordiazepoxide
3. CAcamprosate
4. DNaltrexone
Answer and explanation in LearnFree account

Substance use and withdrawal

In the CAGE questionnaire for alcohol use, what does the letter E ask about?

A 31-year-old man on a methadone programme is brought to casualty unresponsive, with pinpoint pupils and a respiratory rate of 6/min, after taking extra doses. IV naloxone 0.4 mg wakes him within two minutes and he wants to leave. What is the next best step?

A 23-year-old woman at 14 weeks of pregnancy has had hyperemesis gravidarum for six weeks and has been on IV dextrose saline for ten days. She now has confusion, horizontal nystagmus, diplopia and an unsteady gait. Serum sodium is 136 mmol/L and glucose 98 mg/dL. What is the next best step?

A 48-year-old daily-wage worker who has drunk arrack heavily for 20 years is brought to casualty confused. He has nystagmus, bilateral lateral rectus palsy and a broad-based unsteady gait. Deficiency of which vitamin is responsible?

A 36-year-old man on disulfiram after alcohol detoxification drinks two pegs at a wedding. Within 20 minutes he has facial flushing, throbbing headache, vomiting, palpitations and a fall in blood pressure. Accumulation of which substance causes these symptoms?

A 50-year-old man with chronic alcohol use is admitted with confusion and ataxia. Wernicke encephalopathy is suspected and thiamine is started. To confirm thiamine deficiency, the laboratory measures the activity of which red cell enzyme before and after adding thiamine pyrophosphate?

A 39-year-old autorickshaw driver cut down his heavy drinking two days ago. He is fully oriented and has no tremor, but he hears several men discussing him and threatening to beat him, and he has barricaded his room. Vitals are normal. What is the most likely diagnosis?

A 33-year-old man on opioid substitution is switched from buprenorphine alone to a sublingual tablet of buprenorphine combined with naloxone. Why is naloxone added?

A 25-year-old man in a de-addiction centre in Amritsar is 18 hours from his last dose of heroin. He has yawning, watering eyes, running nose, dilated pupils, gooseflesh, abdominal cramps and diarrhoea. He refuses opioid substitution. Which drug best relieves his autonomic symptoms?

A 52-year-old man who drinks a litre of whisky a day is admitted for elective hernia surgery. Twelve hours after his last drink he becomes tremulous, sweaty and anxious, with pulse 112/min. Liver function is normal. Which drug is preferred to treat his withdrawal?

A 29-year-old man who injects heroin is enrolled at an opioid substitution therapy centre. His first dose of sublingual buprenorphine is given four hours after his last injection. Within an hour he has severe sweating, cramps, vomiting and diarrhoea. What explains this reaction?

A 47-year-old man with alcohol dependence and compensated cirrhosis (bilirubin 2.1 mg/dL, ascites controlled) has completed detoxification and wants a drug to reduce craving. His creatinine is normal. Which drug is most suitable?