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NBME 21 Answers

nbme21/Block 2/Question#18 (40.7 difficulty score)
A 34-year-old woman comes to the physician ...
“I’m concerned about how bad you’ve been feeling lately. Have you had any thoughts about death or wanting to be dead?”🔍

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submitted by yotsubato(1032),
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llWe hastt a aelrly ucedr ywa to sceren for .s.eensdorp.i

champagnesupernova3  There's really no other way to say it without using euphemisms +3  
drdoom  You can’t rule out suicidal thoughts via inference. +  
drdoom  LAWYER: Did you ask the patient if she was suicidal? DOCTOR: Well, um, no, not exactly — but, I mean, she seemed okay .. +  
drdoom  LAWYER: So, a patient walks into your office, you suspect post partum depression — a diagnosis with known suicide risk — and you didn't ask if she was suicidal? +  
drdoom  DOCTOR: gulp +  
beetbox  @drdoom wow ok now this will stick to me forever. Always ask your patient so I can avoid lawsuits! +1  

submitted by consuela_salon(23),
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thaw I got form isht :suoqetni EERVN %(99 of eht emt)i ferre a aetinpt ot see ynnaeo

madojo  I was convinced this one was the exception, but guess not, NEVER REFER! +  

submitted by neonem(571),
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thisisfine   Found this difficult because FA characterizes "thoughts of harming baby or self" as postpartum psychosis - which is super rare, and doesn't fit this case. Also, CBT is first line treatment for postpartum depression - so I still like the offer to refer to a therapist as the best choice. +11  
d_holles  Same @thisisfine. +2  
chandlerbas  i see what youre saying but we should make sure that the mother is alive for us to refer to a therapist. remember if shes willing to harm herself most likely also willing to harm the the little cutie asking for suicidal thoughts screens for progression to post partum psychosis with the aim to prevent the sentinel event: harm to the baby +  

submitted by drzed(220),

SIGECAPS criteria: (1) feeling weepy/overwhelmed, (2) fatigue/irritability, (3) anhedonia, (4) difficulty sleeping, (5) "I feel guilty...", for a period of 6 weeks = meets the criteria for a depressive episode, and since this was in the post partum period, may be post partum depression.

Next best step is to screen for suicidal ideation/thoughts of harming the child.

submitted by bbr(25),

"Has it come as a surprise to you how hard parenting is? Many people feel that way." I don't think this validates their feelings, and it would make someone feel badly if you said "hey everyone deals with this shit". Also this answer focused on parenting, rather than the psychiatric concern (postpartum depression).

"im concerned about how bad you've been feeling lately". I think this does acknowledge their feelings, and does show that the physician is engaged. Yes, its blunt. But at its worst, its still more complete than the other ones.

Tough question based on you're reading style.

drdoom  if a disease or syndrome has known risk of suicide, and you fail to assess for it, that's negligence brotha (“if you suspect, you must protect!”) +  

submitted by an_improved_me(13),

I totally get how asking about suicide, and asking about it directly is important. But my confusion is how this answer doesn't provide any good segue. I went with "has it come as a surprise..." because i figured that would lend itself nicely to the patient opening up. When i feel it is appripriate, i would then bring up the conversation about self-harm, harming the baby, and suicide. But as its written, the patient tells you they feel shitty, and the physician very directly says "wow you feel pretty shitty". Seems very insensitive and not optimal for honest communication.

an_improved_me  Also, while i hear some people saying that making it seem like her problems aren't unique... well thats actually the point in a lot of conversations with patients-- making them feel not alone. I don't think i would feel great knowing that all other parents instantly love their kids, and have no problems taking care of them. Instead, I'd want to feel like whatever i'm feeling isn't abnormal and unnatural. "I feel like a bad parent"; "that's rare, most people feel like great parents" "thanks doc". Yikes. +