Title: Usmle Step 1 MCQ's # 19
Subject: Behavioral Science
Q NO 19: A 60-year-old male executive with a history of angina pectoris and depression had bypass surgery the previous day. His depression has responded well to selective serotonin reuptake inhibitors (SSRIs) and there is no history of psychosis in the past. He now presents with confusion, agitation, irritability, and tries to remove his IV lines. His level of consciousness fluctuates, and at times he forgets who he is. He is given a neuroleptic drug, and appears much improved. What is the most likely diagnosis?
A. Adjustment disorder
B. Delirium
C. Dementia
D. Exacerbation of depression with suicidal ideation and psychotic features
E. Schizophrenia
Explanation:
The correct answer is B. Delirium is a common complication of general anesthesia and surgery. It is manifested by acute changes in mental status with waxing and waning level of consciousness, agitation, irritability, and psychosis. Patients usually respond to low-dose neuroleptics to achieve sedation. The course is self-limited.
Any psychosocial or biological stressor can lead to adjustment disorder (choice A). This patient’s surgery will restrict his level of functioning, at least in the short term. This will be difficult for a high-functioning individual to accept. Adjustment disorder may present with depressive mood, anxiety, and irritability, but a fluctuating level of consciousness is not a feature of this disorder.
Dementia (choice C) can present with irritability, confusion, and agitation, but usually has an insidious course and affects mainly cognition. In contrast to delirium, it does not have a fluctuating course.
Severe depression can present with irritability, suicidal ideation, and psychotic features (choice D) . The patient has a history of depression that responded well to SSRIs and he has no prior history of psychosis. He was motivated to undergo cardiac surgery, so removing his IV lines is unlikely to be a manifestation of suicidal ideation.
Schizophrenia (choice E) presents with bizarre behavior, hallucinations, and delusions. It usually starts at a younger age than the acute symptoms in this patient, and is characterized by progressive deterioration in functioning. It is unlikely for a schizophrenic to achieve the functional level of an executive.
Subject: Behavioral Science
Q NO 19: A 60-year-old male executive with a history of angina pectoris and depression had bypass surgery the previous day. His depression has responded well to selective serotonin reuptake inhibitors (SSRIs) and there is no history of psychosis in the past. He now presents with confusion, agitation, irritability, and tries to remove his IV lines. His level of consciousness fluctuates, and at times he forgets who he is. He is given a neuroleptic drug, and appears much improved. What is the most likely diagnosis?
A. Adjustment disorder
B. Delirium
C. Dementia
D. Exacerbation of depression with suicidal ideation and psychotic features
E. Schizophrenia
Explanation:
The correct answer is B. Delirium is a common complication of general anesthesia and surgery. It is manifested by acute changes in mental status with waxing and waning level of consciousness, agitation, irritability, and psychosis. Patients usually respond to low-dose neuroleptics to achieve sedation. The course is self-limited.
Any psychosocial or biological stressor can lead to adjustment disorder (choice A). This patient’s surgery will restrict his level of functioning, at least in the short term. This will be difficult for a high-functioning individual to accept. Adjustment disorder may present with depressive mood, anxiety, and irritability, but a fluctuating level of consciousness is not a feature of this disorder.
Dementia (choice C) can present with irritability, confusion, and agitation, but usually has an insidious course and affects mainly cognition. In contrast to delirium, it does not have a fluctuating course.
Severe depression can present with irritability, suicidal ideation, and psychotic features (choice D) . The patient has a history of depression that responded well to SSRIs and he has no prior history of psychosis. He was motivated to undergo cardiac surgery, so removing his IV lines is unlikely to be a manifestation of suicidal ideation.
Schizophrenia (choice E) presents with bizarre behavior, hallucinations, and delusions. It usually starts at a younger age than the acute symptoms in this patient, and is characterized by progressive deterioration in functioning. It is unlikely for a schizophrenic to achieve the functional level of an executive.
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