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A 68-year-old man comes to the physician because of a 5-week history of fatigue, difficulty concentrating, increased appetite, and an increased need for sleep; he has had a 2.0kg (4.4-lb) weight gain during this period. He reports not attending church for the past 4 weeks because he has been tired. He has a 11-year history of type 2 diabetes mellitus well controlled with diet and glyburide therapy. Over the past 2 years, his blood glucose concentrations had been within the reference ranges. He drinks 1 to 2 beers on the weekends and doesn't use illicit drugs. Physical and neurologic examinations show no changes. He makes poor eye contact and has a restricted affect. His serum glucose is 210 mg/dL and HbA1c is 10%. His CBC and metabolic profile are within reference ranges. Which of the following is the most likely cause of this patient's current lack of glycemic control?

a.) Sleep Apnea
b.) Delirium
c.) Multi-infarct (vascular) dementia
d.) Adjustment reaction with depressed mood
e.) Dementia, Alzheimer type
f.) Major depressive disorder
g.) Schizophrenia
 

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The presentation actually goes along atypical depression; food and sleep indulgence, and feelings of fatigue. All other items do not apply at all. There's no history supporting any of them. If we go with the closest to the correct answer, it would be f.) Major depressive disorder (where there's usually less sleep) -- but I'm not convinced.
 

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e.) Dementia, Alzheimer type - I am choosing this because of his age.


a.) Sleep Apnea - very vague symptoms with no specific pointers towards obesity, also i don't see a direct connection with glycemic worsening.

b.) Delirium - Again, nothing specific that points towards this case.

c.) Multi-infarct (vascular) dementia - since his glycemia has been under control i didn't think it was the right option.

d.) Adjustment reaction with depressed mood - don't know much about this currently.

f.) Major depressive disorder - again no specific pointers, the time period might be too early to even diagnose this condition.

g.) Schizophrenia

This is my reasoning, many of the things i said could be wrong because i haven't done the Psychiatry yet.
 

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a.) Sleep Apnea

I think Sleep apnea does alter the normal hypothalamic-pituitary-adrenal axis activity by increasing cortisol. This would explain the poor glycemic control due to insulin insensitivity.
Increased cortisol can also cause depression. This would explain the depressive symptoms in this pt.
Considering the person is already a pt of Type 2 DM this also puts him at increased risk of developing sleep apnea.

I hope i am rite though...:scared:
 
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Dont want to insult, but is this very difficult to put in TITLE that this is NBME 7 question. Many people left NBME form 7 for online assessment before exam.

And one more, to forum administration. Please put sticky note, first in row: If you want to post NBME questions, mark them properly.

Thanks
 

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well it can not be sleep apnea...because metabolic profile are within reference ranges...in sleep apnea one will have respiratory acidosis...n no other symptoms r mentioned like excessive snoring at night...

5-week history of fatigue, difficulty concentrating, increased appetite, and an increased need for sleep; he has had a 2.0kg (4.4-lb) weight gain during this period. He reports not attending church for the past 4 weeks because he has been tired...He makes poor eye contact and has a restricted affect...
these r all classical symptoms of major depression...
in depression there can be increased or decreased appetite...as well as increased or decreased sleep....

cause of this patient's current lack of glycemic control..is change in appetite....
 

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the answer is major depression


but I might argue with adjustment reaction with depressed mood.

-the events is less than 6 months.
-it caused by chronic medical condition.
-impairment in social and occupational functioning.(work and church)
-show poor attention to grooming or give statements inconsistent with emotional state (affect)
-Depressed mood may be associated with low volume and output of speech, blank or sad expression, and decreased or slowed spontaneous movement (psycho-motor retardation). The mental status examination may reveal a decrease in attention and concentration.

-you can't diagnose dementia according to age only. the patient gave details in history unlike Alzheimer.
-sleep apnea . is a wrong answer too. the patient showing restricted affect , or at least they should say something about over weight not weight gain.
-the rest of choices are too far from the stem .
 

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Answer must be major depression. There is NO STRESSOR mentioned in
the question.

Adjustment disorder occurs following some stressful event or multiple stressors and results in impaired social functioning, symptoms start within 3 months of some stressful event.
 
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