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1 1 PCL 1 - Case 6: Session 1 James Carter dickinsonstateu. (2011). Mike Nekuda cropped [electronic image]. Retrieved from:

2 James Carter Interview between James and his physician, Dr. Leonard Coe Interview between James Carter (JC) and Dr. Leonard Coe (MD) MD: Hello, I’m Dr. Coe and you are James Carter? Dr. Carter? Which do you prefer? JC: James is fine. Thanks for squeezing me in for this appointment. MD: No problem – we always try to make time for house staff. I see here that you are a resident in anesthesia. What year? JC: This is my first year of residency – I did an internship in New York last year. MD: Was that a categorical program or did you change over in midyear? JC: I transferred – I always wanted to do anesthesia, but I didn’t match initially so I had to reapply. I was lucky to find a spot after just one year. MD: I’m glad things worked out – so how can I help you? JC: Well, I’ve come in because I’m so damn tired all the time! I can hardly make it through a full day – last week I fell asleep during a case conference. I drag through everything and I never seem to get enough sleep. I’m afraid one day I might nod off during a long procedure or something! N.A. (N.D.) [electronic image of male doctor]. Retrieved from:

3 James Carter Interview between James and his physician, Dr. Leonard Coe MD: I assume that this feeling is different from the usual tiredness of being a house officer? JC: This is definitely different. There is no good reason for me to feel like this. I’m not as busy as I was as an intern – right now I’m doing a pain management elective which is about as easy as my program gets! MD: Is there more bothering you than just tiredness? JC: Well, I’ve been getting lots of headaches and muscle aches – and I don’t feel much like eating. MD: Have you actually lost weight? JC: Only a few pounds – ten, fifteen maybe. But I used to go to the gym a lot and I’m really out of shape now. I hate the way I look and feel! MD: Any other systemic symptoms – fever, a cough, joint pain.. ? JC: Just a general achiness – more of a heaviness, really. My arms and legs feel like lead, as though I’m walking through water. MD: You mentioned you don’t get enough sleep. Is it that you can’t sleep when you want to or that you need more sleep than normal?

4 James Carter Interview between James and his physician, Dr. Leonard Coe JC: Well, I guess the problem is that I can’t fall asleep for about two hours after I go to bed and then I wake up early – even earlier than I have to for rounds. So during the day, I could just nod off any time. MD: How long has this been going on? JC: I don’t know – maybe six, eight weeks. Since about three months after we moved down here, more or less. MD: Did the tiredness start at the same time? JC: Pretty much, I guess. MD: How would you say your mood has been? Have you been feeling down, or anxious? JC: Um, well, you know, I am kind of anxious lately. MD: What about anxious feelings in your body – sweating, trembling, butterflies in your stomach and so on? JC: I’m pretty restless – I seem to go between being a total slug and not being able to sit still. And inside I have this shaking feeling, like I might fall apart - if that makes sense. My heart rate has gone up, too – when I was training it was about 60, now it’s sometimes 70 or 80.

5 James Carter Interview between James and his physician, Dr. Leonard Coe MD: What about actual panic attacks – do you know what I mean by that? JC: I think I had one last week – but that was the first one I ever had. MD: Tell me what that was like. JC: Well, it was after I had had a couple really bad nights. Even though I was post call, I had only slept maybe five hours. And I had to run this really long case with an attending I hardly knew. He was a nice enough guy, but I couldn’t keep my mind on what I was doing. He asked me to adjust the infusion rate for one of the anesthetics and I couldn’t think for a minute what it was – and then I just panicked. My heart was racing, I could hardly breathe, and my knees felt weak. MD: Then what happened? JC: I apologized and asked if I could take a break. In about five minutes, I felt better. MD: Are you afraid of something like that happening again? JC: Yeah, for sure! I have been in the OR at least two or three times a week, even on this elective. MD: Do you have any other particular worries? Things that you just can’t easily put out of your mind?

6 James Carter Interview between James and his physician, Dr. Leonard Coe JC: I’m sure you are going to think that I’m nuts – but I really worry that maybe this is leukemia or Hodgkin’s disease. MD: That is a pretty grim thought. JC: Well, it’s got to be something like that – I’ve never felt this bad before. Now that you mention panic – could this be pheo?! MD: I don’t think we can say just yet. Let me ask a couple more questions – have you had mono? JC: In high school – just a mild case. And my PPD was negative last month. MD: What about HIV? JC: Negative as of last month. And I’ve been vaccinated for Hepatitis. MD: That’s good. Any other chronic medical conditions? JC: No, I’ve always been really healthy. MD: Do you take any medications regularly?

7 James Carter Interview between James and his physician, Dr. Leonard Coe JC: Vitamins and creatine sometimes, when I’m working out regularly. MD: Any steroids? JC: Never – I’m not that much of a fanatic. MD: How about drinking, or recreational drugs? JC: No drugs – not since high school. MD: Do you drink alcohol? JC: This is confidential, isn’t it? I mean this can’t get back to my program director or anything, right? MD: Well, not entirely. If I thought you were an alcoholic, I would be obligated to report it to the medical society and they might want to investigate further. Are you worried that alcohol might be a problem? JC: No, not now. But I was a pretty heavy binge drinker in college. And it affected my grades in the first year of med school – may have been why I didn’t match the first time around. MD: What about current drinking?

8 James Carter Interview between James and his physician, Dr. Leonard Coe JC: I’m really careful now. I might drink some when I am not on call - but never, never before a work day. MD: How many drinks might you have in a week? JC: Maybe ten, total. MD: How many drinks might you have in one evening? JC: I’ve cut down a lot. Five is my absolute limit – I don’t have the head for it I used to. MD: I see, so what do you think is going on? JC: I wish I thought it was just stress, but honestly things in my program are not that bad. I’m doing what I always wanted to do and I should be able to handle it. That’s why I think there is something really wrong with me. MD: Does that mean that you aren’t doing as well as you expect yourself to do? JC: I can’t concentrate well enough to study for more than a half hour or so and I can’t seem to get motivated at all. MD: Is there anything you still enjoy like you used to?

9 James Carter Interview between James and his physician, Dr. Leonard Coe JC: Not much – I mean some days aren’t as bad as others, but I never really feel like myself. I used to be pretty social, and I love to play basketball. Now all I want to do is sit home and watch TV. And I can’t even get excited about the NCAA tournament like I normally would this time of year. MD: Tell me again about your mood. Would you describe it as blue, or sad, or down? JC: Yeah, I’m pretty down. MD: Have you had any crying spells? JC: It’s funny – a lot of the time I feel like I wish I could cry, but I can’t. MD: What about thoughts of death, or suicide? JC: If this is leukemia, I think I might want to end it right there. I mean, I’ve seen what people go through when they are getting chemo, and I don’t think I would want that. MD: Let’s not jump to conclusions. Any other thoughts about hurting yourself? JC: No, I mean, life doesn’t seem all that worth living right now, but I’m not about to jump off a bridge or anything. MD: Tiredness comes from so many things – I think I should examine you and get some lab work, and then we can talk about what might be going on.

10 10 Learning Objectives Add what you’ve learned to: Clinical Notes Add what you’ve learned to: Clinical Notes

11 James Carter Physical Examination 11 Blood pressure: 118/75 Pulse: 64 Respiratory Rate: 12 Temperature: 98.6 o F. General Observation: Muscular young man, sits forward in his chair, often looks at the floor. Occasionally rubs his hands over his face. Expression is tense. Head, Eyes, Ears, Nose, and Throat (HEENT) Examination: Pupils Equal, Round, Reactive to Light and Accommodation (PERRLA), no oral or nasal lesions, pharynx within normal limits. Neck: Thyroid not palpable. No palpable lymph nodes. Chest: CTAB. Heart: RRR, no murmurs, rubs, or gallops. Abdomen: No masses, liver 7cm to palpation, edge not felt. No tenderness. Extremities: Muscle strength 5 throughout. Pulses 2+ and symmetrical. No joint swelling. No inguinal lymph nodes. No bruises or petechiae. Neuro: Cranial nerves II-XII WNL. Reflexes 2+ and symmetrical. No focal weaknesses. No tremor. Sensation not tested. Nl gait.

12 James Carter Laboratory Results 12 Hematology RBC: 3.87 M/CMM (3.8-5.2) HGB: 13.2 GM/DL (11.5-16.0) HCT: 38.1% (35.0-47.0) MCV: 99 FL (80-100) MCH: 34.0 PG (26.4-34.0) MCHC: 34.5 G/DL (31.0-36.0) WBC: 5.7 K/CMM (3.9-11.3) BANDS: 0% (0-10) POLYS: 67% (42-78) LYMPHS: 22% (15-45) MONOS: 5% (0-12) EOSIN: 6% (0-7) BASOS: 0% (0-2) ATYP LYMPH: 0% (0-4) COMMENT: Platelets appear adequate Chemistry GLUCOSE: 88 MG (65-115) SODIUM: 141 MEQ/L POTASSIUM: 4.3 MEQ/L (3.5-5.5) BUN: 9 MG/DL (5-25) CREATININE: 0.9 MG/DL (0.5-1.4) CHLORIDE: 106 MEQ/L (95-110) HCO3: 23 MEQ/L (18-30) CALCIUM: 9.4 MG/DL (8.6-10.6) LDH: 122 IU/L (100-250) AST: 20 IU/L (8-35) ALT (SGPT): 6 IU/L (0-40) ALK PHOS: 40 IU/L (30-130) TOT. BILI: 1.0 MG/DL (0.2-1.5) DIR. BILI: 0.3 MG/DL (0.0-0.5) IND. BILI: 0.7 MG/DL (0.1-1.3) TOT. PROT: 6.7 G/DL (6.3-8.5) ALBUMIN: 4.0 G/DL (3.7-5.2) THYROID STIMULATING HORMONE (TSH): 2.0 uIU/ml (0.40-4.2)

13 James Carter Second Interview between James and his physician, Dr. Leonard Coe MD: I’m glad that you could get away to come down and meet with me. I wanted to let you know your lab work was completely fine. There is no sign of any malignancy. Your blood pressure is also fine. You certainly don’t have leukemia, pheo, or Hodgkin’s disease. JC: Well, that’s good I guess – but I still feel terrible. You don’t think maybe you ought to do a 24 hour urine for catechols or something? MD: When your resting pressure is so normal, the chance that you have a pheo is basically nil. It’s not that you don’t have a problem, you do. It’s just that I think your problem is depression, which can produce awful fatigue like you’ve been having and also the many anxiety symptoms you mentioned. But I have to say, I am also concerned about your drinking. The absolute level of alcohol you’re using isn’t off the charts, but the pattern of your drinking given the known effects of alcohol on depression do worry me. JC: Look, my Dad is an alcoholic, and I know I’m not like him MD: I wouldn’t call this alcoholism, but anyone who is depressed really shouldn’t drink at all. And you do have a number of other risk factors that suggest that alcohol could become a worse problem in the future. You have a pretty high tolerance and a family history it sounds like. JC: Well, I guess I have been pretty depressed lately. So, are you going to prescribe some vitamin P?

14 James Carter Second Interview between James and his physician, Dr. Leonard Coe MD: Vitamin P? JC: You know, Prozac. MD: Ah, I’ve never heard it called that before – anyway, the thing is, I can’t be sure whether or not the depression is from the drinking or you are just drinking so much because you’re depressed – do you see what I mean? The only way to be sure is for you to completely give up alcohol for a month. I would like to refer you to a psychiatrist who could follow you during that month, and then decide if some kind of antidepressant treatment is necessary. But the choice is really yours. JC: Psychiatrist, huh? Do you think that is necessary? MD: Would you object? JC: Well, the ones I’ve met in the past didn’t impress me a whole lot. They tend to be kind of vague and wishy-washy. At Bellevue, where I interned, most of the psych residents were either pseudo-neurologists or pompous Freud wannabes. Not all of them, but a good many. MD: I know a couple I think you would find it easy to work with, and if it turns out this clears up with you not drinking, it wouldn’t take much of your time.. JC: I don’t know – I guess right now, being on clinics, I could make the time. But I really don’t want to spend 6 months gazing at my navel or reliving my childhood or whatever.

15 James Carter Second Interview between James and his physician, Dr. Leonard Coe MD: The one I most recommend is Dr. Booker – he is used to working with house staff and he won’t do more than is necessary. You need someone very up to date about medication, and for that alone a psychiatrist’s opinion would help. In my experience, a depression like this doesn’t just come from out of the blue. If you just take medication, even if it works, you won’t understand why you got depressed and what might you need to do to prevent it in the future. JC: I guess. Well, why don’t you give me Dr. Booker’s number and I’ll call him. MD: I’m glad you are willing to see Dr. Booker and abstain from drinking for the time being. It can be hard to change habits, especially when you are in a stressful new job and I think letting someone else help you is just a really smart move on your part. Let me know how it goes, okay? JC: Okay.

16 James Carter Return to: Problem List/Learning Objectives slide Clinical Notes slides – add any new information you gained from the second interview between Dr. Coe and James.

17 17 James Carter Session 1 Wrap Up NEXT SESSION: Student Presentations: Students will prepare presentations based on the outcomes/problems that were identified during class. Be sure to assign a student to present Handout 1: Medical Objective 1 - Basic Science of Depression and Its Treatment. Also assign individuals to cover 4 contextual objectives during the third session – each of these students will be given a handout at the end of the 2 nd session giving them more information about their objectives – please do not distribute these handouts until the end of the second session as the handouts discuss elements of the case that will not arise until during the 2 nd session.

18 18 James Carter Session 1 Wrap Up NEXT SESSION: Required Reading Handout 1: Medical Objective 1 - Basic Science of Depression and Its Treatment (this is available on Blackboard.) All students will look this over and one student will lead the discussion of the materials covered here as described on the previous slide.

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20 20 PCL 1 - Case 6: Session 2 James Carter

21 21  Librarian Presentation: Informatics objectives  Presentations: Learning objectives identified by the group plus someone covering “Medical Objective 1: Basic Science of Depression and Its Treatment.”Learning objectives  Continue slides for the case. James Carter Management of Session 2

22 22 Informatics Objectives Librarian Presentation of Informatics objectives

23 James Carter Interview between James and psychiatrist, Dr. Richard Booker James follows Dr. Coe’s advice – it takes six weeks for him to get a psychiatric appointment. Although he does feel a bit less tired, he remains anhedonic, pessimistic, and unmotivated. He returns to Dr. Coe while waiting for the first psychiatric visit and is prescribed fluoxetine (Prozac) and encouraged to remain sober. Finally he has a first psychiatric visit... MD: It’s good to meet you, Dr. Carter. Dr. Coe sent me his report, so I know he has told you he thinks you’re depressed. How are you doing now? JC: Well, now I am on an ICU rotation, and I don’t feel all that much better to be honest. I am still tense all the time. MD: Okay - tell me, since you started the Prozac, have you noticed any change? JC: I think it might be making me worse actually! About three days after I started it, I had a horrendous panic attack-it went on for a good hour! MD: Can you tell me more about it? JC: Let’s see. I was post-call, and I was driving back from the hospital. It was kind of dark and rainy, but not that bad. All of a sudden, my heart started to race, I was sweating and sick, and I had this pressure in my chest like a rock sitting on it. I really thought I was having a heart attack! MD: What happened then? N.A. (N.D.) [electronic image of male doctor]. Retrieved from:

24 James Carter Interview between James and psychiatrist, Dr. Richard Booker JC: I pulled off the highway and I figured I’d wait awhile, and if it got worse, I’d just go to the nearest emergency room. In a few minutes, I felt better, but I couldn’t get back on the road – I thought about what would happen if I had an MI at 70 miles an hour. SO I went home by a lot of dinky roads which took forever. MD: Have you had any problems driving since then? JC: I’m still really uncomfortable about getting on the highway, but I have to do it to get to work, so I do. MD: Have there been any other changes? JC: I guess I’m feeling a little better just in the past few days – I’ve been sleeping more at night which helps. Last week, though, I did feel, well, I mean I know I wouldn’t have done it or anything – but, well, I did come pretty close to swallowing the whole bottle of Prozac along with a fifth of scotch and hoping that would do it. MD: You thought you wanted to die? JC: I guess I really didn’t, but yes, I was thinking that way. MD: Please tell me more about what was happening – Dr. Coe’s report was thorough, but I still don’t feel I know that much about you.

25 James Carter Interview between James and psychiatrist, Dr. Richard Booker JC: I was at home and the person I live with was getting ready to go out. We had an argument about it - one we’ve had a few times before. Anyway, after I was alone, I got into this really bleak mood and I thought, “Screw it. If it’s going to be like this, I might as well just give up.” MD: What prevented you from acting on this thought? JC: I don’t know. I was just kind of sitting there, brooding, too pooped to get up and do anything about it. And I started thinking about how my parents would feel, and my friends, and I guess I realized I was overreacting. MD: Was there anyone you thought of calling? JC: Not really – I mean, I really knew all along that I wouldn’t do anything, I just had the thought. And this week, I haven’t felt nearly that bad, now that I think about it. MD: Is this the first time you’ve thought about suicide, or come close? JC: No. Hmmmm. Actually, I remember when I was in high school, I had just had my first sexual experience. It was with a classmate, a guy I sort of had a crush on. That week two guys on the football team beat me up, called me a “fag” and “queer”. I really didn’t know who to turn to. I thought everyone knew my secret, so I went home, took a handful of aspirin and immediately got sick to my stomach. I never told anyone what happened. It’s funny, I had forgotten all about that incident.

26 James Carter Interview between James and psychiatrist, Dr. Richard Booker Dr. Booker does a more thorough risk assessment. He also reviews with James the early side effects of Prozac, which sometimes makes anxiety worse before it gets better. They talk about how the risk of suicide sometimes increases temporarily when people start an antidepressant, because they can get more anxious or get energy and motivation while they still feel deeply depressed. Dr. Booker reiterates the importance of abstaining from drinking while depressed. James assures the doctor he is not suicidal and he agrees to talk with his partner or a friend should the symptoms recur (“contract for safety”). MD: You mentioned that you live with someone – can you tell me a little more about that relationship? JC: I guess it must be obvious that I am gay. My partner is named Eric. We’ve been together for about four years now. But since we’ve moved down here, we’ve had all kinds of problems. MD: What kinds of problems? Eric artnoose (2010) Matt in Santa Cruz. Retrieved from: Victoria Belanger. (2009). Metro 01 [electronic image]. Retrieved from: Julicath (2008) Ma douce Filleule Deli-cat [electronic image]. Retrieved from:

27 James Carter Interview between James and psychiatrist, Dr. Richard Booker JC: Well, when we were in New York, we were both out to everybody – his family knew, and mine, and all our friends. And when I got this residency in DC, we both thought that Washington would be the same. But the gay community is a whole lot smaller than in New York. Being new to GW, I want to learn the ‘lay of the land’ before being too open about myself So I wanted to take it real slow, getting out and socializing and meeting new people. I didn’t want anything to get back to my program. I’m just not sure how people will react. Maybe I’m overthinking things, I don’t know... MD: How has that affected the relationship? JC: It’s totally different for Eric. After I matched, he got a job with a human rights lobbying group, and of course everybody there is totally accepting. But we both miss our old friends, and Eric wants to get out there and meet people and do things. At the beginning, I just said I was too tired or had to study too much – which was true. But now he is beginning to have a whole new circle of people, and it is obvious that I am hanging back. MD: Was that an issue, the night you got suicidal?

28 James Carter Interview between James and psychiatrist, Dr. Richard Booker JC: Yeah, he was going to see a movie downtown, and then a whole bunch of people were going clubbing afterwards. He knew I didn’t have to go in the next day, and he called me on my not wanting to join him. It’s funny, he thought maybe I was getting interested in someone else, when really, that’s my fear about him! MD: You’ve been worried he might be seeing someone else? JC: Yes and that just panics me. This has been a great relationship, the best I’ve ever had, and I don’t want to lose him. But I’ve wanted to do anesthesia ever since I wanted to be a doctor, and this is a great place for me. I don’t want to choose between them, and it’s tearing me up!

29 James Carter Return to: Problem List/Learning Objectives slide Clinical Notes slides – add any new information you gained from the first interview between Dr. Booker and James.

30 James Carter Second Interview between James and psychiatrist, Dr. Richard Booker After three more weeks, Dr. Carter is feeling a lot better. His energy and concentration are back to normal, he is sleeping well, and he and Eric are talking more openly about the problems he faces in his program. He has had no more suicidal ideation, no more panic attacks, and he can look back in amusement at his fear that he was dangerously ill. MD: Tell me how things have gone this past week. JC: Things are much better. Eric and I went up to a big concert in Baltimore, and we both had a great time. We’ve been careful not to go to public events in Washington – he would still like to, but he’s willing to humor me. But we do invite over people we know, and we’ve been to a few private parties. I’ve been drinking a little bit, but like you said, when we are having dinner. I’ve kept it to three drinks once a week, and it doesn’t seem to be much of a problem. MD: Well, that sounds reasonable – and you did say Eric didn’t really like your drinking so much before. JC: He even cut back himself so that I would, and we both don’t miss it like I thought we would. Really, I’m beginning to think I’ve gotten past the worst of it. In fact, this week I missed a couple doses of my medication, and I didn’t feel much different. I think maybe I’ll just stop. MD: I’m not sure that’s such a good idea. Why would you want to stop it? JC: Well, actually, you know how it is with Prozac. I mean, I don’t feel depressed anymore, but I kind of don’t feel much of anything. Particularly now that we are getting along better, (cont.)

31 James Carter Second Interview between James and psychiatrist, Dr. Richard Booker JC: Eric is eager to make love more often, and I don’t have as much interest, really hardly any. I used to be the one to start things, but now I barely think about it. MD: If you do have sex, is there any problem? JC: It just takes me forever to finish – Eric doesn’t mind, but I find it very frustrating. MD: We need to talk about this. You are right that these sexual problems are probably from the Prozac, but if you stop it this soon after a serious depression, you are very, very likely to have a relapse. JC: So I can be happy or have sex, but not both? What a choice! MD: It’s hardly that bad. I have some ideas that may help.

32 James Carter Return to: Problem List/Learning Objectives slide Clinical Notes slides – add any new information you gained from the second interview between Dr. Booker and James.

33 33 James Carter Overview of Learning Objectives for Students (These Will Not Be Tested as Part of PCL) Clinical Reasoning  List the core elements of a descriptive, empirical diagnosis and formulation in a depressed patient.  Define ‘comorbidity’.  Differentiate Risk Factors from Clinical Criteria.  Identify the elements of suicide risk assessment.  Begin to practice Clinical Case presentations. Basic Sciences  Define major depression in terms of it’s epidemiology, diagnosis, and treatment.  List medical conditions that produce fatigue and aches and pains and set priorities in the diagnostic evaluation of these complaints.  List conditions that are comorbid with depression.  Explain how psychosocial factors interact with neurophysiological processes to produce clinical illness.  Relate the mechanisms of anti-depressant drug action to the pathophysiology of depression.  Describe the core therapeutic elements of psychotherapy.

34 34 James Carter Overview of Learning Objectives for Students (These Will Be Tested as Part of PCL) Contextual Objectives  List unique stresses that afflict homosexuals and members of other stigmatized populations, especially stresses that relate to seeking health care.  Explain why homosexual adolescents have an increased rate of suicide attempts.  Describe the typical qualities of depressed thought (cognitive distortions).  Discuss how relational processes contribute to or buffer people against developing depression.  Discuss the unique and shared stressors in physicians’ relationships generally.  Discuss the context of mental health care (primary vs. specialist settings) as it affects outcome. Informatics Objectives  Practice selection and evaluation of information resources to support PCL research.  Summarize types of resources available in Psychiatry Online and Scopus.

35 35 James Carter Session 2 Wrap Up NEXT SESSION:  Contextual Objective Presentations – Distribute the Appropriate Handouts 1.“Depression” (Handout 2: Contextual Objective #1: Depression) 2.“Contract for Safety and Risk Assessment” (Handout 3: Contextual Objective #2-Contract for Safety and Risk Assessment) 3.“Relationships of Medical Professionals” (Handout 4: Contextual Objective #3-Relationships of Medical Professionals) 4.“Psychotherapist” (Handout 5: Contextual Objective #4- Psychotherapist)  Every student should prepare a BPS Formulation to discuss during the third class session  Practice USMLE Questions  Feedback & Discussion

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37 37 PCL 1 - Case 4: Session 3 James Carter

38 38 James Carter Management of Session 3  Contextual Objective Presentations 1-4.  Have Students Pair Off to Discuss Their Biopsychosocial Formulations and then Distribute Handout 6: Sample Biopsychosocial Formulation and Discuss  USMLE Questions  At the end of class distribute Handout 7: All Contextual Objectives for Students & Handout 8: Resources for Students Needing Academic, Personal, or Mental Health Counseling  Feedback & Review Case Objectives: Were all of the learning objectives covered?learning objectives

39 39 USMLE Questions Q1: A thirty year old woman seeks care for difficulty falling asleep and waking up too early in the mornings. On questioning, she also acknowledges that she has little appetite, she cries frequently, she finds little to enjoy in life, and her sex drive is almost nonexistent. These symptoms point to dysregulation of A. Hypothalamic Pituitary Adrenal Axis B. Inter hemispheric communication (corpus collosum) C. Cortical imbalance of GABA/Glutamate activity D. Dysfunction of the nigrostriatal dopamine system

40 40 USMLE Questions A. Hypothalamic Pituitary Adrenal Axis Explanation: The vegetative signs of depression (sleep problem, lack of libido and changes in appetite) imply dysfunction in the subcortical rhythms of cns function. Negative thinking and cognitive dysfunction (concentration) reflect cortical processes. The nigrostriatal dopamine system regulate movement. The mesolimbic system regulates the capacity to experience pleasure. The role of inter hemispheric communication or imbalance between the hemispheres is undetermined.

41 41 USMLE Questions Q2: A 14 year old boy tells the pediatrician he thinks he is homosexual. He describes experimenting sexually with older boys. What should the pediatrician focus on in further discussion? A.Does he also have sexual interest or experiences with girls? B.Has he experienced bullying or exclusion by his classmates? C.Has he come out to his parents and classmates? D.Does he know if any of his male relatives are homosexual?

42 42 USMLE Questions B. Has he experienced bullying or exclusion by his classmates? Explanation: The medical risks for homosexual adolescents are exposures to STDs and suicidal behavior primarily. The latter is usually the result of bullying, victimization, stigma, or rejection. Whether the boy is bisexual, or perhaps just experimenting, is of much less concern than focusing on known risks to his health.

43 43 USMLE Questions Q3: The psychiatrist who is treating James Carter decides to conduct interpersonal psychotherapy. This suggests that he will focus on A.James’ hopelessness and all or nothing thinking. B.The impasse that seems to characterize his relationship with Eric. C.The problems he is having in the transition from an intern to a resident role. D.The lack of pleasurable activity in James’ life.

44 44 USMLE Questions C. The problems he is having in the transition from an intern to a resident role. Explanation: Interpersonal psychotherapy, by definition, focusses on one of four typical depression related concerns: loss, role transition, role disputes, and developmental deficits. Although James is in the midst of a role transition, this is not the source of his distress. Focus on negative thinking and lack of pleasurable activity typify cognitive behavioral therapy.

45 45 James Carter Session 3 Wrap Up  Feedback: o Give feedback to the Student Case Leader o Did students accomplish all of the objectives?  Teamwork?  What worked? What did not work?  Next Time: the case of Judy Johnson!  Choose a Student to be the Case Leader for Case VII: Judy Johnson

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47 CC: (Chief Complaint/Concern): HPI: (History of Present Illness): PMH: (Past Medical History): 47 Past Surgical History:

48 FH: (Family History):Medications: Allergies: SH: (Social History):

49 Assessment & Plan: Labs: Review of Systems: Physical Exam:

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