CCS Interactive Case 6

Question 1

40 y/o F presenting with 2 months of depressive symptoms, leading to leave of absence from work

Exam steps?

Answer 1

Complete physical exam including psychiatric assessment

Question 2

Exam reveals malnourishment, psychomotor retardation, absence of delusions/hallucinations, no sign of underlying medical illness

Next steps?

Answer 2

TSH, BMP, B12, CBC

[Additional tests if high suspicion - EKG if dysrhythmia suspected, ANA if SLE suspected, HIV and VDRL if high risk sexual behavior, UTox and blood tox screening if suspected substance abuse, dexamethasone suppression test for suspected Cushing’s, cosyntropin stimulation test for suspected Addison’s]

Initiate treatment pending diagnostic testing results

Question 3

Rx?

Answer 3

• Psychotherapy or pharmacotherapy for ild to moderate
• Pharmacotherapy or ECT for moderate to severe
• Admission and ECT in patients with suicidal behavior and severe functional impairment

SSRIs (fluoxetine) - Rx of choice
Short-acting benzo (lorazepam) tapered dose for 1-2 weeks in cases with anxiety/insomnia while antidepressant therapy is initiated
Atypical antipsychotic for associated psychotic symptoms

F/u - every 1-2 weeks for 6-8 weeks for mild/moderate, weekly for 6-8

Question 4

When to consult psychiatry?

Answer 4

First line produces no improvement in 6-8 weeks
Severe SI
Associated psychiatric, medical, or substance abuse disorders

Question 5

Sequence:

Answer 5

No emergency orders
Physical exam (full)
Tests - CBC, BMP, TSH, B12 (routine)
Therapy: SSRI or other antidepressant, counseling, medication compliance, regular exercise, patient education (do not send home without antidepressant)
Home
Schedule appointment in 10 days
Arrive - interval follow-up, general, neurologic/psychologic exam
Location - home
Schedule appointment in 14 days
Case ends
Dx - MDD