Case Vignettes Flashcards
A 48-year-old man presents to clinic for his physical. He reveals to you that he hasn’t been sleeping well for the past few months, and has felt like he is drained of energy, to the point that he doesn’t have much interest in his work or hobbies, and finds it difficult to concentrate at work. He says he feels sluggish, and has been moving slower than usual as well. Overall, he says, he has been feeling “down.” He reports no history of difficulty sleeping before this point. What are the criteria to come up with a diagnosis for this patient, and what might you want to rule out?
Major Depressive Disorder: 5 of the following (including at least one of the first two):
1. depressed mood
2. diminished interest or pleasure (anhedonia)
3. weight loss or weight gain (or change in
appetite)
4. insomnia or hypersomnia
5. psychomotor agitation or retardation
6. fatigue or loss of energy
7. feeling worthless or excessively guilty
8. decreased concentration or indecisiveness
9. suicidal ideation
The symptoms cause clinically significant distress or
impairment in social, occupational, or other important
areas of functioning.
Can be remembered as SIGECAPS: •change in Sleep •loss of Interest •Guilt •lack of Energy •poor Concentration •change in Appetite •Psychomotor retardation or agitation •Suicidal ideation
Things to rule out:
The episode is not attributable to the physiological
effects of a substance or another medical condition (hypothyroid, for example, or sleep disorders - you’d have to rule those out)
The occurrence of the major depressive episode is not
better explained by schizoaffective disorder,
schizophrenia, schizophreniform disorder, delusional
disorder, or other specified and unspecified schizophrenia
spectrum and other psychotic disorders
There has never been a manic episode or a hypomanic
episode (ruling out bipolar disorder)
You are taking a history from a 57-year-old woman. She tells you, “I’m a prophet. I hear the divine word through my television. It’s my job to save everyone I know from the apocalypse.” What kind of findings are these, and how will you document them? What kind of diagnosis might she have?
Delusions - specifically religious delusions
Ideas of reference - feels like TV, radio, or other media is speaking directly to them.
These findings could be present in schizophrenia, schizoaffective disorder, mania associated with bipolar disorder type I, or anything with psychotic symptoms.
You are evaluating a patient for opioid use disorder. The patient has some reservations about starting methadone or buprenorphine, and says, “I don’t want to end up dying of an overdose, but I don’t have the time to commit to these kinds of intensive treatment.” What are some approaches you can take with this patient to ensure that the patient gets appropriate therapy?
1) Motivational interviewing. You’ve already elicited change talk (“I don’t want to end up dying of an overdose”) but the patient has resistance to change and ambivalence about change. You could try reflections (“You’re worried that taking these medications will take a lot of time, but you don’t want to die of an overdose”) in order to elicit more change talk. You should also try the Explore-Provide-Explore model of structuring interventions (explore what the patient thinks, provide more info with permission, explore their reaction).
2) On the side of opioid interventions, you may want to discuss the pros and cons of methadone treatment and buprenorphine treatment.
- Methadone requires treatment at a treatment center, and supervision of the person taking the medications, but is effective if patients are compliant. It doesn’t have a risk of inducing withdrawal when you take it.
- Buprenorphine can be provided by a physician who has been trained to do so, so it doesn’t require a treatment center. It can also be given in combo with naloxone (as Suboxone) to prevent overdose if the patient tries to overdose. It does have a risk of inducing withdrawal since it has such high affinity for the receptor.
Jane is a 21-year-old patient who you are treating for depression. She is curious about what causes depression, and asks you if it’s true that depression is caused by a neurotransmitter imbalance. How do you answer her, and how do you explain some of the possible theories for the etiology of depression?
It’s true that manipulation of serotonin signaling is important in the mechanism of action of many antidepressants. However, the etiology of depression probably is due to changes in neuro plasticity. The current reigning theory for the etiology of depression is that depression is a failure of neuroplasticity. Increased glucocorticoids from stress lead to decreased neurogenesis, and increased glutamate leads to excitotoxicity. Glucocorticoids also block BDNF (brain-derived natriuretic peptide), which is needed for neural remodeling and neuroplasticity. However, this theory is not perfect and more research is needed.
Mike is a 44-year-old man who comes to your clinic for a physical. When you ask him how things are going at work, he tells you that he has been having some difficulties. He says, “I don’t think my manager and I get along very well. I’m not sure what I did, but he really seems to dislike me. I’m sure it’s because I turned in a report late to him three months ago, and since then I’ve just felt like he’s very hostile to me. It’s not like he’s said anything, but he’s always scowling any time I see him around the office, and I just feel like I must not be performing up to standard to make him feel that way.” What kind of cognitive distortion(s) do you identify in this statement?
Personalization - “it must be something I did”
Over generalization - “I’m always messing up”
Using the language of cognitive distortions, how would you describe this common sentiment experienced by medical students? “Why am I not studying all the time? I should be studying more. I should probably be putting in several more hours each day. If I don’t study enough, then I’ll fail the test, and then I’ll have to retake it, and might have to retake the block!” At what point does this cross the line into a pathological state?
Shoulds and musts - “I should be doing X”
Catastrophizing - “If I don’t do X, then Y will happen, and then Z…”
This becomes pathological when it causes significant distress or impairment to the person having these thoughts.
John Smith is a 25-year-old man who tells you at his physical that when he gets very stressed at his job, he tends to come home and yell at his wife. What kind of psychological defense is he manifesting, and how mature would you consider it to be?
Acting out - he’s taking an action rather than reflecting on the problem or thinking about his feelings. This is one of the least mature psychological defenses.
Mary Smith is a 47-year-old woman with type 2 diabetes and obesity. At her physical, she tells you, “When I was first diagnosed with diabetes, and had to learn to eat fewer carbs, I tried not to think too hard about it and I basically pretended I didn’t have diabetes. Kept on baking cookies, cakes, muffins, and eating them whenever I felt like it. Now, though, I’ve learned to control it, and when I feel like baking, well, I maybe save one muffin for myself and bring the rest of the batch down to the local food pantry. I get to bake, and I’m helping someone out too.” What two psychological defenses did she describe?
Denial - early after her diagnosis, she refused to acknowledge that she had T2DM
Altruism - she channels her feelings about her diabetes into serving others
Your patient is a woman who has experienced a sexual assault. She tells you, “When I see mentions of sexual assault on social media, I’ve taught myself not to feel anything. It’s like I make myself numb on purpose. That way I don’t feel upset or trigger a panic attack.” What psychological defense is she describing?
Isolation of affect
Kate is a 40-year-old woman who presents to clinic for a routine physical. You take a thorough history and find that overall she has been healthy, except for a year-long depressive episode when she was 25. She has never been suicidal. Her family history is significant for her mother’s struggles with anxiety and depression. She does not currently feel depressed, and has no concerns with her mental or physical health today. Kate wants to know what kind of risk she has for future episodes of depression. How do you answer her?
Risk factors for depression include F>M, family history (somewhat heritable), history of stressful life events including childhood abuse, comorbidities with alcohol use, substance use, personality disorders, anxiety disorders, and previous episodes. While baseline risk for depressive episodes is about 16%, having had one previous episode increases the chance of recurrence to 50%, which continues to increase with more previous episodes. Other medical conditions may also lead to depressive symptoms.
In Kate’s case, her risk of recurrence is about 50%, given that she has had a previous episode of depression. She also has a family history of depression, which does contribute to that risk.
A 65-year-old man presents to the ED and appears to be unresponsive to verbal stimuli. He has no known history of trauma. You immediately begin an exam, including a full neuro exam. You find that his left pupil is slightly dilated and sluggish in response to light, and he has a positive Babinski sign in response to the plantar reflex test on his right foot. He displays appropriate motor responses to noxious stimuli. His breathing is eupneic. You decide to order an emergent CT scan to check for structural abnormalities. What are you checking for, and what do you suspect is going on?
Checking for structural abnormalities that could be causing an uncal herniation, specifically a temporal mass or a bleed near the temporal lobe that could cause it to herniate through the tentorial notch. That would compress cranial nerve III, leading to some of the symptoms seen. As the uncal herniation progresses, it may cause cerebral peduncle compression, which could lead to contralateral hemiparesis, decreasing level of consciousness, and potentially death.
A 45-year-old woman presents to the ED after a motor vehicle accident. She is stabilized in the ED, has surgery to fix her broken femur, and is admitted to your internal medicine service. She wakes up from surgery without complications, although complains of a headache over the next day or two. About 3 days after being admitted to your service, she begins to experience visual hallucinations and appears agitated. Her body temperature is 40 degrees, her pulse is 130, and her respiratory rate is 28. Her blood pressure is elevated as well. She is diaphoretic and flushed. Blood cultures, urine cultures, and a lumbar puncture rule out infection, and you detect no illicit substances in her blood and urine. What may be going on, and how would you treat it?
This is a classic presentation of delirium tremens in alcohol withdrawal. Delirium tremens can be lethal if untreated. Its symptoms are clouding of the sensorium, hallucinations, agitation, and increased autonomic activity. It tends to occur 2-14 days after the last drink. It is often seen in patients who are admitted to the hospital and have no access to alcohol, and therefore go into alcohol withdrawal. It is treated with benzodiazepines, which ramp up GABA-A receptor activation, causing inhibition that calms down the symptoms.
A 22-year-old man is dropped off at the ED by his friends, who say that he seems to be “out of control.” In the ED, he is oriented to person and place but not to time, and he is very agitated. He has a grand mal seizure while he is being triaged. His vitals are all elevated. His friends tell you that he was at a concert, and had “several drinks, probably at least 5 shots,” but they cannot account for anything else he was doing over the course of the night. What are you concerned might be going on?
Cocaine intoxication - vitals will be up, altered mentation, agitation, seizures. In contrast, cocaine withdrawal presents with decreased mood and fatigue. This scenario rules out alcohol withdrawal because he has had multiple alcoholic drinks very recently. However, if he has an alcohol use disorder, he might be at risk of alcohol withdrawal if he is admitted.
A 32-year-old woman is dropped at the front door of the ED in a state of altered level of consciousness. She is oriented to person but not place or time, and is very sleepy. In order to get any information from her, you have to continually wake her up. Her respiratory rate is 10. There are track marks on her arms. You find in her chart that she has a history of repeated visits to this ED for chronic knee pain. What drugs should you be considering, and how might you treat this patient?
1: opioids, given her history and the track marks. Treatment should be naloxone, given multiple times if needed to end her opioid intoxication.
A patient who has been in the hospital for 2 days is given IV fluids that include glucose. The patient rapidly develops ataxia, ophthalmoplegia, and confusion. The patient has no history of neurological disorders. What is this syndrome, and what is a potential cause?
This is Wernicke’s encephalopathy, caused by giving glucose without thiamine in a patient in alcohol withdrawal. It occurs because thiamine is a cofactor in glucose metabolism, and the moment glucose is given, all the thiamine is essentially sucked out of the system. This is a problem because thiamine is needed in nerves as well. Giving thiamine before giving glucose can prevent this from occurring.
A patient presents to the ED with facial numbness on the left side. At this moment, the patient is hemodynamically stable. You immediately do a neuro exam. You find that the patient has reduced sensation to the skin of the face on the left forehead and upper cheek, ptosis, asymmetric pupils, and decreased extraocular movements on the left side. What do you expect might have caused this?
A lesion - aneurysm, stroke, tumor, etc. in the left cavernous sinus could cause these symptoms, as CN III, IV, V1, V2, and VI all appear to be affected in this patient.
A 75-year-old patient presents to the ED. The patient is hemodynamically unstable, with a blood pressure of 80/50. The patient’s wife tells you that the patient was fine until an hour ago, then got a severe headache and started to become less and less responsive. There is no history of trauma. On CT you see a lentiform-shaped area of brightness. What is going on in this patient?
Epidural hemorrhage, usually due to rupture of a meningeal artery, typically the middle meningeal. Blood will not cross the sutures of skull bones. This is a very fast bleed and needs to be treated immediately.
A 36-year-old woman presents to your primary care clinic today for a follow-up after a surgery for carpal tunnel release. You have seen her before for management of depression and anxiety, and for follow-up after a suicide attempt 2 years prior. Today she seems very upset, and says, “My surgeon was the absolute worst! She wouldn’t listen to me at all, and I honestly don’t think she did a very good job. I’m in so much pain after the surgery, and it’s making me really anxious! That’s why I came to see you - you’re the only doctor I can trust to really understand my needs.” The surgical site appears to be healing nicely, and you tell her this, which makes her very happy. She thanks you profusely. You send her home, but she calls your clinic three times over the next week to ask questions about her surgery, and leaves four messages on MyChart asking for your advice as well. This is not unusual in comparison to previous encounters with this patient. What might be an underlying issue in this patient?
Borderline Personality Disorder! Characterized by interpersonal problems, affective instability, behavioral difficulties, and cognitive problems. It may lead to frequent suicide attempts, and has a lot of psych comorbidities. 5 factors are frequently present in the etiology - early separation or loss, disturbed parental involvement, verbal or emotional abuse, sexual abuse, neglect. Psychotherapy, especially DBT and psychodynamic psychotherapy, are the treatments of choice. It’s best to deal with present emotions and relationships rather than past ones. Meds are not a good choice for managing these patients.
