Discussion in 'USMLE STEP 2 CS' started by Dr. Johnson, Mar 25, 2005.

  1. Dr. Johnson

    Dr. Johnson Guest

    40-year-old woman who has become withdrawn
    This case scenario will be presented in a different format in that the answers given by the SP will be given in parentheses
    In the whole patient encounter the SP will be in a most disinterested mood and will talk in a feeble voice
    The doctor should always make eye contact with the patient
    The paucity of speech from the patient should not frustrate the doctor

    Simulated encounter
    Hello Mrs. Ortiz. My name is Dr. Johnson. I am here to ask you a few questions and do a physical on you. Is that ok
    with you. (The SP will nod feebly)
    What brings you in today (I don’t know Doctor. I feel a bit down)
    Since when have you been feeling this way (3 months. Maybe)
    Mrs. Ortiz; do you think that something has brought this on.( She remains silent)
    Mrs. Ortiz; I know that you are in a lot of emotional stress. Are you willing to share your problems with me? (The
    patient looks at the doctor and then away)
    Do you think any thing has brought this on (I don’t think so)
    Do you have anybody to talk to you when you feel down (I have an aunt. She stays far away)
    Mrs. Ortiz…. How has your appetite been of late (I don’t feel like eating)
    Mrs. Ortiz…. Have you lost or gained any weight recently (my weight decreased by 7 lbs over the past one month)
    How has your sleep been? (I am getting up early in the morning)
    Do you feel guilty for any reason ( I don’t think I am being a good mom for my children)
    Do you feel any tiredness (I don’t feel that I have any energy at all. I just don’t want to get out of the couch)
    Mrs. Ortiz… Please describe your daily routine for me (I am a house wife. I do the housework and cook for my
    children. That’s about it.)
    Can you tell me if you have any hobbies and interests (I play violin and sing in the choir on Sundays; but now don’t
    feel like doing that anymore)
    Do you feel that you are losing your power of concentration (mmm I don’t know)
    Are you forgetting things more often (Yeah. I am forgetting to pay the bills etc)
    What do you enjoy most (Spending time with my children)
    Do you still enjoy it (I don’t feel like I want to be with any body right now)
    Mrs. Ortiz… Have you ever felt like ending your life because you felt that it wasn’t worth living? (Yeah – a couple
    of times)
    Do you have any ideas on how to do it (No)
    Do you have guns or pills at home (Yeah. I have a .32 at home)
    Do you feel cold when others don’t (no)
    Are you losing any hair (no)
    Have you ever listened to or seen anything that others don't ( no)
    Please do an MMSE at this juncture
    Do you think that some thing is going wrong with you (Yeah)
    Are you willing to get help from a counselor (I don’t know)
    I can get you in touch with one. (If you feel that would help me.)
    Now I need to ask you a few questions about your health in the past. Is that ok with you (Yeah)
    Have you ever been hospitalized in the past (No except for the deliveries of my children)
    Have you ever felt like this in the past (no)
    Are you on any medications (no)
    Do you have any allergies of any kind (none that I know of)
    Do you have any problems with your urination (no)
    Do you have any problems with your digestion or your bowels (I have been constipated of late)
    Have you ever had any shortness of breath (no)
    Have you ever had any chest pain (no)
    Have you had cough that just wouldn’t go away? (no)
    Now I need to ask you a few personal questions. Please do not feel embarrassed. Everything you say will be kept
    Are you sexually active (yes)
    How many sexual partners do you have-A couple of them
    Your sexual preference is ….(males )
    Do your sexual partners use condoms (Yes they do)
    Have you ever been diagnosed or treated for an STD (no)
    Have you ever been tested for HIV (no)
    Now I need to ask you a few questions about your family so that I can get a clearer picture of your health
    Are you married (I was. Got a divorce 10 years ago)
    Are your parents living (no. They died of old age)
    Has any one in your family been diagnosed with a psychiatric disorder (no)
    How many children do you have(2. The elder one is 14. The younger one is 11)
    Now I need to ask you a few questions about your lifestyle.
    Do you use tobacco (no)
    Do you drink any type of alcoholic beverages? (Yeah. I have 2 shots of scotch on the rocks. Been doing so for the
    past 10 years.)
    Do you use any recreational drugs (no)
    Do you drink coffee (Yeah. One cup every morning)
    Now I need to do a physical on you. Please excuse me for a few seconds while I wash my hands
    I am going to check your thyroid gland (Not palpable)
    I am going to check your reflexes (2+)
    I am going to check your pulse now
    I am going to listen to your heart and lungs now.
    Thank you Mrs. Ortiz for your cooperation.
    I am going to sit down and tell you what I think so far
    I feel that you are having an episode of depression though I wouldn’t definitely say it before the results of some tests
    that I am going to run on you.
    I am going to order a blood test on you to find out if you have any problems with your thyroid. After the results
    come in I would sit with you again and then we can discuss how we can make you feel better.
    Is there anything else that I can do for you?

    Differential Diagnosis
    Occult carcinoma

    T3 T4 TSH
    CBC with differential
    Urine and serum toxicology screen
  2. usmlemaniac

    usmlemaniac Guest

    withdrawn woman

    Here is my 2 cents about the case.

    1. Always start out with an open ended question. In this case "What brings you in today" is good.

    2. Ask her about depression. The mnemonic is SIG CAP E . Which stands for sleep, irritable, guilt, concentration, pyschomotor agitation, energy is low. Depression is part of the differential diagnosis of withdrawn

    3. Then use PAM HUG FOSS mnemonic which stands for

    P- Past Medical History
    A- Allergy
    M- Medication

    H- Hospitalization
    U- Urinary System
    G- Gastrointestinal

    F-Family History
    O- OB history
    S- Social history
    S- Sexualy history

    You think about depression. Here are the DSM IV criteria for depression:
    A. At least 5 of the following, during the same 2-week period, representing a change from previous functioning; must include either (a) or (b):

    (a) Depressed mood
    (b) Diminished interest or pleasure
    (c) Significant weight loss or gain
    (d) Insomnia or hypersomnia
    (e) Psychomotor agitation or retardation
    (f) Fatigue or loss of energy
    (g) Feelings of worthlessness
    (h) Diminished ability to think or concentrate; indecisiveness
    (i) Recurrent thoughts of death, suicidal ideation, suicide attempt, or specific plan for suicide
    B. Symptoms do not meet criteria for a mixed episode (ie, meets criteria for both manic and depressive episode).

    C. Symptoms cause clinically significant distress or impairment of functioning.

    D. Symptoms are not due to the direct physiologic effects of a substance or a general medical condition.

    E. Symptoms are not better accounted for by bereavement, ie, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

    For the differential diagnosis, you want to expand it out:
    Adjustment Disorders
    Anorexia Nervosa
    Anxiety Disorders
    Apnea, Sleep
    Bipolar Affective Disorder
    Cannabis Compound Abuse
    Chronic Fatigue Syndrome
    Cushing Syndrome
    Dissociative Disorders
    Dysthymic Disorder
    Graves Disease
    Hashimoto Thyroiditis
    Hypopituitarism (Panhypopituitarism)
    Lyme Disease
    Obsessive-Compulsive Disorder
    Opioid Abuse
    Panic Disorder
    Personality Disorders
    Phobic Disorders
    Porphyria, Acute Intermittent
    Posttraumatic Stress Disorder
    Premenstrual Dysphoric Disorder
    Primary Hypersomnia
    Primary Insomnia
    Schizoaffective Disorder
    Schizophreniform Disorder
    Sedative, Hypnotic, Anxiolytic Use Disorders
    Sleep Apnea
    Sleep Disorder, Geriatric
    Sleeping Disorders
    Somatoform Disorders
    Systemic Lupus Erythematosus
    Thyroiditis, Subacute
    Vascular Dementia
    Wernicke-Korsakoff Syndrome

    For the workup

    CBC count
    Thyroid-stimulating hormone (TSH)
    Antinuclear antibody (ANA)
    Erythrocyte sedimentation rate (ESR)
    Vitamin B-12
    Rapid plasma reagin (RPR)
    HIV test
    Electrolytes and calcium levels and renal function test
    Liver function tests
    Blood alcohol, blood, and urine toxicology screen
    Dexamethasone suppression test (Cushing disease)
    Cosyntropin stimulation test (Addison disease)

Share This Page