First Aid for the USMLE Step 2 CS

Section 3. Minicases

Depressed Mood

Key History

Onset, duration; sleep patterns; appetite and weight change; drug and alcohol use; life stresses, excessive guilt, sui- cidality, social function, decreased interest (anhedonia), decreased energy, decreased concentration, psychomotor agitation or retardation; family history of mood disorders; prior episodes; medications.

Key Physical Exam

Vital signs; head and neck exam; neurologic exam; mental status exam, including documentation of appearance, behavior, speech, mood, affect, thought process, thought content, cognition (measured by the 30-point mini-mental status exam), insight, and judgment.

Presentation

Differential

Workup

■ 68 yo M presents with a 2-month history of crying spells, excessive sleep, poor hygiene, and a 15-lb (6.8-kg) weight loss, all following his wife’s death. He cannot enjoy time with his grandchildren and admits to thinking he has seen his dead wife in line at the supermarket or standing in the kitchen making dinner.

Normal bereavement

Adjustment disorder with depressed mood Major depressive disorder with psychotic features Schizoaffective disorder Depressive disorder not otherwise specified

Physical exam

TSH

CBC

Urine toxicology Beck Depression Inventory

■ 42 yo F presents with a 4-week history of excessive fatigue, insomnia, and anhedonia. She states that she thinks constantly about death. She has suffered 5 similar episodes in the past, the first in her 20s, and has made 2 previous suicide attempts. She further admits to increased alcohol use in the past month.

Major depressive disorder

Substance-induced mood disorder

Dysthymic disorder

Physical exam Mental status exam Beck Depression Inventory Blood alcohol level TSH CBC

Urine toxicology

■ 26 yo F presents with a 6.5-lb (2.9-kg) weight loss in the past 2 months, accompanied by early-morning awakening, excessive guilt, and psychomotor retardation. She does not identify a trigger for the depressive episode but reports several weeks of increased energy, sexual promiscuity, irresponsible spending, and racing thoughts approximately 6 months before her presentation.

Bipolar I disorder

Bipolar II disorder Cyclothymic disorder Major depressive disorder Schizoaffective disorder

Physical exam Mental status exam Urine toxicology





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