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NBME 20 Answers

nbme20/Block 1/Question#15 (reveal difficulty score)
A 30-year-old man who completed a successful ...
Adjustment disorder with anxiety 🔍 / 📺 / 🌳

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submitted by aladar50(41),
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oS h’rtees 001 srendts,ie nad het reelvneapc trfea 2 earsy is 10= at teh g,inbignne 5+ ni hte rstfi ,arey +10 soednc ,yare adn -3 htat el,haed rof a olatt eplrenecva of 22 esirnstde or =2021202/ r.eectpn hu,Ts vpeclernea = veboa the artdndsa. rFo cicennid,e st’i 51 wne cssae uot of 90 rtiednsse reov teh 2 ryeas 100( otalt eistrdnes – 01 thta yedalar hda lusr,ec) or 15 enw lsecur rep 018 taa.rnieptes⋅y Tish luwdo be 83.3 nwe elursc epr 1000 aepneai⋅ttrsy fi yuo xlapeodtaetr it tuo -- ayclslaib 81(001)00/ * 15 -- uht,s eincceind = vbeoa teh ddtrasna.

submitted by hayayah(1174),
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tnoDfienii fo djmtsetanu s:roidred

ntlaoomiE myomspst (g,e xatyine, es)esrdonpi htta ocucr iwnith 3 tsnohm fo an naiiiefdlebt pocssoalcihy etrsosrs g,e( vcoider, )sllneis ngilats l&t; 6 nmthos enoc teh setossrr hsa ee.ddn

fI tymsspom riptses &;gt 6 mthnso feart terosrss edns, ti is AGD.

hello  Yep, and I think what we are supposed to take from this Q is: The only info. we have for this patient is that he ended chemo 2 months ago and has been calling the doctor a lot -- this is supposed to mean he has been calling a lot since ending chemo 2 months ago. His frequent calls starting after ending chemo and within 3 months of the stressor fits with the above-stated definition of "adjustment disorder" with anxiety. I stressor in this case could possibly be either the actual illness or the ending of chemo/treatment. It probably does not matter much in this case. +6  
charcot_bouchard  I think doing uw done me wrong here. Adjustment disorder isnt diagnosed when symptom match another disorder --- it was like never a right answer. But ofc its right answer in nbme +5  
maxillarythirdmolar  Just to add to that, the tingling in his fingers may seem like a distraction/it probably is. Likely has some relation to his Chemo. +3  
j44n  shit I thought this poor guy had OCD with all the repetitive behaviors. +2  

submitted by johnthurtjr(160),
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hleWi I can egt on dbora htwi seuAjnmtdt roreDd,is I 'tnod ees hwo tihs nwrase is ayn treebt tnah aioStcm yompmSt edosrrD.i ormF A:F

atyVeri fo dobily aplomnicts atlgsin tnsohm to sarey desitasoca hitw ee,sevxcis eperttsnsi hhostugt adn yxteian uoatb ystm.msop yaM paaro-cep wthi .lilsnse

DSS besnlgo in a puorg of edirrssdo tzracreehcaid by pysiaclh stsmyopm sagnciu fnsntigiiac sseidsrt dan rnpm.eaitmi

savdaddy  I think part of it stems from the fact that this patients symptoms are occurring within the time-frame for adjustment disorder while SSD seems to have a longer timeline. Aside from that I find it difficult to see why SSD wasn't a possible answer. +4  
chillqd  To add to that, I inferred that the obsession with checking temp and with the tingling sensation were signs provided to him by the physicians of recurrence. He is anxious over his cancer recurring, and they are more specific than a variety of body complaints +2  
hello  In somatic symptom disorder, the motivation is unconscious. I think for the patient in this Q-stem, his motivation is conscious -- he wants to make sure that recurrence of cancer is not going "undetected". +19  
cienfuegos  I also had issues differentiating these two and ultimately went with SSD, but upon further review it seems that a key differentiating feature was the timeline. His somatic symptoms would have had to have been present for at least 6 months per the DSM criteria +3  
almondbreeze  @chillqd Same! Why not OCD? He's fearful that something bad might happen (=cancer relapse; obsession) and calling his doc (=compulsion) +  
kevin  great reasoning @hello, this was confusing me but that makes perfect sense +1  

submitted by arkanaftus(14),
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eTh esbt eawrsn olwud eb eslslnI txynAie esDr,doir rwheevo ti si ont an ontopi hre,e teferroeh it 'tcna be tgr.hi.. so E.MB..N

j123  Both somatic sx disorder and illness anxiety disorder must be persistent for >6 months. Since this pt has only been acting excessively worried for 2 months, then it would have to be Adjustment disorder with Anxiety. (PS I got this question wrong since I at first thought Somatic Sx disorder) +3  

submitted by foodi(0),
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ywh act'n sith eb CDO? fist het meit aerfm, hsi ssnobiesos era chncgeik shi temp dan he leevsrie sheet ihwt inglalc the hacspiniy o.upso.s(cnil)m.

hiroshimi  According to DSM-5, with OCD, the disturbance is not better explained by the symptoms of another mental disorder such as preoccupation with having an illness, as in illness anxiety disorder. In his case, he was previously dx with cancer, treated, then develop these anxieties that he may have missed some sign is more fitted with illness anxiety disorder. Moreover, OCD is characterized by ego-dystonic, which is "thoughts, impulses, and behaviors that are felt to be repugnant, distressing, unacceptable or inconsistent with one's self-concept", which clearly doesn't apply to the pt case, as checking the temperature is actually meaningful and goal-directed. +1  
utap2001  I think the most important hints are stressor and timeframe. I believe the description in the Q stem have some distractor. Maybe the definition of OCD should be no reason. A stressor and <3 month time make adjustment disorder more likely. +  

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