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Old 01-08-2011
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Question NBME form 3 - The psychiatric cause of this weight loss

A 77-year-old man comes to the physician because of a 3-month history of fatigue and decreased appetite resulting in a 4.5-kg (10-Ib) weight loss. He also has had depressed mood and decreased concentration. He is no longer interested in participating in his weekly golf outing and rarely attempts to visit with friends. He is no longer motivated to clean his house and keep up with his bills. He says he can hear his wife, who has been dead for 4 years, telling him that his loss of appetite is due to cancer and that he should end his life before he goes through the same painful death that she did. Physical examination shows no abnormalities. Mental status examination shows a depressed mood. He is able to recall two of three objects after 5 minutes. There is no evidence of suicidal ideation. Which of the following is the most likely diagnosis?

A) Adjustment disorder with depressed mood
B) Dysthymic disorder
C) Major depressive disorder with psychotic features
D) Pathological bereavement
E) Schizoaffective disorder

Please I need explanation for your choice.
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Old 01-08-2011
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C) Major depressive disorder with psychotic features
His wife has been dead three years so it cannot be normal grieving (which can only last up to one year)
Dysthymia: is a milder form of depression lasting at least 2 years (question says 3 months)
Schizoaffective disorder is 2 weeks of stable mood and then psychotic symptoms + depressive/manic bipolar.
Adjustment disorder would require something to have changed prior to the 3 month onset of depression (since his wife passed 4 years ago it is unlikely that that would be the cause)

Answer C includes that he has major depression (loss of interest, loss of weight...) and psychotic features (talking to his dead wife and her asking him to kill himself)
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Old 01-08-2011
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Quote:
Originally Posted by ms.med View Post
C) Major depressive disorder with psychotic features
His wife has been dead three years so it cannot be normal grieving (which can only last up to one year)
Dysthymia: is a milder form of depression lasting at least 2 years (question says 3 months)
Schizoaffective disorder is 2 weeks of stable mood and then psychotic symptoms + depressive/manic bipolar.
Adjustment disorder would require something to have changed prior to the 3 month onset of depression (since his wife passed 4 years ago it is unlikely that that would be the cause)

Answer C includes that he has major depression (loss of interest, loss of weight...) and psychotic features (talking to his dead wife and her asking him to kill himself)
So you think that this pt is experiencing major depressive disorder with psychosis. This is very tricky and time consuming type of qn. Thank you so much for your brief excellent explanation.
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Old 01-09-2011
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based on kaplan LN yes C is right....

confusing question but i think the key is the duration of the symptoms...
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Old 01-09-2011
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Thats my analysis too - it's not:

a) or e) because personality disorders are lifetime conditions and these are not applicable here.

and it's not b or d because both of these only deal one of either the mood symptoms OR the psychotic features.

Option C is the only on that deals with both mood and psychotic features of this patient's illness. And, as has been stated above (grief is pathological after all this time so this counts as major depression) and the psychotic features are his hearing of voices - ie: auditory hallucinations)

I'd treat this patient with antipsychotics and antidepressants.


Quote:
Originally Posted by aktorque View Post
A 77-year-old man comes to the physician because of a 3-month history of fatigue and decreased appetite resulting in a 4.5-kg (10-Ib) weight loss. He also has had depressed mood and decreased concentration. He is no longer interested in participating in his weekly golf outing and rarely attempts to visit with friends. He is no longer motivated to clean his house and keep up with his bills. He says he can hear his wife, who has been dead for 4 years, telling him that his loss of appetite is due to cancer and that he should end his life before he goes through the same painful death that she did. Physical examination shows no abnormalities. Mental status examination shows a depressed mood. He is able to recall two of three objects after 5 minutes. There is no evidence of suicidal ideation. Which of the following is the most likely diagnosis?

A) Adjustment disorder with depressed mood
B) Dysthymic disorder
C) Major depressive disorder with psychotic features
D) Pathological bereavement
E) Schizoaffective disorder

Please I need explanation for your choice.
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