depression

Eight weeks after having her first child, 32-year-old Mrs. CK (G1P1) makes an appointment to see you. Since the birth of her baby, Mrs. CK has been feeling emotionally drained.

Vital Signs: Temperature 97.7°F Blood pressure 105/70 mmHg Heart rate 76 beats per minute Respiratory rate 14 breaths per minute.

Examinee’s Tasks 1. Obtain a focused and relevant history. 2. Discuss your initial diagnostic impressions with the patient. 3. Discuss follow-up tests with the patient. 4. Provide patient education. 5. After seeing the patient, complete paperwork relevant to the case.

Guids to help. SP CHECKLIST FOR MRS. CK

_ 1. asked if my baby was healthy (“Yes.”) 2. asked if I was feeling anxious about caring for my baby (“Yes; this is all new to me; most of the time, I don’t know if I’m doing it right.”) 3. asked about support from my husband (“He took on a second job to help with the bills; he is really tired when he comes home at night.”) 4. asked about communication difficulties with my husband (“I think he’s stressed out about the baby; we don’t talk as much as before.”) 5. asked if I felt less attractive to my husband (“Look at me; I gained so much weight.”) 6. asked about financial problems in the marriage (“We are just making ends meet.”) 7. asked about other family support systems (“My mother went home; she lives 1000 miles away.”) 8. asked me if I was feeling alone (“When the baby was first born, there were always visitors; now no one comes anymore.”) 9. asked me about mood changes, e.g., sleep disturbances, nightmares, loss of appetite, headache, fatigue, forgetfulness (“I am tired all the time; I have no energy.”) 10. asked if I ever thought about harming the baby (“Oh no, never.”)

HISTORY—Include significant positives and negatives from the history of present illness, past medical history, review of systems, and social and family history. Mrs. CK, a 32-year-old woman (G1P1), is 8 weeks postpartum. Since the birth of her healthy baby, she has been feeling drained and has feelings of inadequacy regarding her ability to take care of the child. Her parents and other relatives were helpful during the pregnancy and shortly after she gave birth but have since returned to their homes far away. Now few people visit and there is little support. Her husband is rarely at home to help; he is working a second job for financial reasons and often comes home tired. Financially, the couple is just making ends meet. There is a breakdown in communication between them and she thinks that her husband might be feeling somewhat ignored and neglected since the baby was born. Additionally, because of her weight gain during pregnancy, she feels that her husband is probably finding her unattractive. Mrs. Simmons admits to feeling tired all the time and has no energy. She has no past history of psychiatric problems and has no thoughts of harming the baby. She smokes three cigarettes daily and drinks two beers; she does not use illicit drugs.

PHYSICAL EXAMINATION—Indicate only the pertinent positive and negative findings related to the patient’s chief complaint. T = 97.7°F. BP = 105/70 mmHg. HR = 76 beats/min. RR = 14 breaths/min. The patient is a sad and tearful 32-year-old woman in NAD. She is slightly overweight. 346 MASTERING THE USMLE STEP 2 CS DIFFERENTIAL DIAGNOSIS In order of likelihood, write no more than five differential diagnoses for this patient’s current problems. 1. postpartum depression 2. major depression 3. 4. 5. DIAGNOSTIC WORKUP Immediate plans for no more than five diagnostic studies. 1. support 2. medication 3. TSH level