The patient has not had a menstrual cycle in 4 months; she has experienced symptoms consistent with early pregnancy, such as nausea and fatigue. Intermittent spotting can occur during pregnancy. Intermittent spotting can be caused by vaginal or urinary tract infections, or sexual intercourse. Upon physical examination, the cervix will appear bluish and at the stage of development of our patient, may be more difficult to locate, secondary to being positioned more posteriorly. Also, upon physical examination, an enlarged uterus is palpable in this scenario, which further increases the suspicion of pregnancy. A urine or blood test will be required to confirm the diagnosis.
Ryan: Kistner's Gynecology & Women's Health, 7th ed., Mosby, Inc. 1999.
Chapter 12 - Pediatric and Adolescent Gynecology Marc R. Laufer and Donald P. Goldstein
1. The correct answer is (B) Recommend that the best time to perform BSE is 4-7 days after the first day of the menstrual period
Help each woman establish a regular schedule of self-care. The best time to conduct breast self-examination is right after the menstrual period, or the fourth through the seventh day of the menstrual cycle, when estrogen stimulation is low and the breasts are least congested. Advise the pregnant woman or menopausal woman who is not having menstrual periods to select a familiar date to examine her breasts each month, for example, her birth date or the day the rent is due.
2. The correct answer is (C) Hegar's sign and Goodell's sign
Shortly after the first missed menstrual period, the female genitalia show signs of the hormonal changes of pregnancy. The cervix softens (Goodell's sign) at 4-6 weeks, and the vaginal mucosa and the isthmus of the uterus softens (Hegar's sign) at 6-8 weeks.
The cervix looks cyanotic (Chadwick's sign) at 8-12 weeks. These changes reflect increased vascularity and edema of the cervix, and hypertrophy and hyperplasia of the cervical glands. Tanner's signs refer to sexual maturity ratings in adolescents.
3. Mrs. W is in her first trimester of pregnancy. She is experiencing significant nausea and vomiting and asks if it will get better. Your response is:
(A) "At about the time the baby moves, it will get better.''
(B) "Many women experience nausea and vomiting until the third trimester."
(C) "Did your mother have significant nausea and vomiting?"
(D) "Usually, by the beginning of the second trimester, the nausea and vomiting improve."
The correct answer is (D) "Usually, by the beginning of the second trimester, the nausea and vomiting improve."
The nausea, vomiting, and the fatigue of pregnancy usually improve by weeks 12-16. Fetal movement occurs at approximately 20 weeks gestation.
3. The correct answer is (A) Most likely to be colostrum and considered a normal finding this late in her pregnancy
During the second trimester, colostrum, the precursor of breast milk, may appear. Colostrum is yellow in color and contains more minerals and protein, but less sugar and fat than breast milk.
4. The correct answer is (C) After 20 weeks gestation, the number of centimeters should approximate the number of weeks' gestation
After 20 weeks, the number of centimeters should approximate the number of weeks gestation. Also, at 20 weeks the examiner may feel fetal movement, and the head can be balloted.
5. The correct answer is (B) Fetal presentation
Fetal presentation describes the part of the fetus that is entering the pelvis first. Fetal lie is orientation of the fetal spine to the maternal spine. Attitude is the position of the fetal parts in relation to each other, and fetal variety is the location of the fetal back to the maternal pelvis.
The Anus, Rectum, and Prostate
1. The correct answer is (B) Pilonidal cyst
A pilonidal cyst is identified by the opening of a sinus tract on the skin. It is usually located in the midline superficial to the coccyx or the lower sacrum. There may be a small tuft of hair at the opening, and it may be surrounded by a halo of erythema.
An anorectal fistula is an inflammatory tract that opens at one end of the anus or rectum and at the other end, onto the skin surface or another viscus. The fistula opening is usually located around the anus, not at the lower sacrum. An anal fissure is a painful oval ulceration of the anal canal and is found most commonly in the midline posteriorly inside the rectum/anal canal. Inspection of the anus may show a swollen "sentinel" skin tag just below it and gentle separation of the anal margins may reveal the lower edge of the fissure. A thrombosed external hemorrhoid results in an acute onset of pain, which is increased by sitting and by defecation. There is a tender, swollen, bluish, ovoid mass, which is visible at the anal margin. There is no associated purulent drainage.
2. The correct answer is (B) Internal hemorrhoid
An internal hemorrhoid is an enlargement of the normal vascular cushions that are located above the pectinate line. During defecation, they may cause bleeding. If they prolapse, they are visible as a reddish, moist, protruding mass.
An external hemorrhoid is a dilation of the hemorrhoidal veins that originate below the pectinate line and are covered with skin. They seldom produce symptoms unless thrombosis occurs. If thrombosis occurs, there may be a tender, swollen, bluish, ovoid mass at the anal margin. A rectal prolapse appears as a doughnut or rosette of red tissue. If only the mucosa is involved, then the prolapse is relatively small and shows radiating folds all the way around. If the entire bowel wall is involved, the prolapse is larger and is covered by concentrically circular folds. A rectal polyp is a soft mass that can be pedunculated or sessile; it is located inside the rectum and is not visible at the surface. Rectal polyps are soft and may be difficult to feel on rectal examination; usually they are diagnosed on proctoscopic examination.
3. The correct answer is (A) External hemorrhoid
An external hemorrhoid is a dilation of the hemorrhoidal veins, which originate below the pectinate line and are covered with skin. They seldom produce symptoms unless thrombosis occurs. If thrombosis occurs, there is an acute onset of local pain, which is increased by defecation and by sitting. A tender, swollen, bluish, ovoid mass may be visible at the anal margin.
An internal hemorrhoid is an enlargement of the normal vascular cushions that are located above the pectinate line. During defecation, they may cause bleeding. If they prolapse, they are visible as a reddish, moist, protruding mass. A rectal prolapse appears as a doughnut or rosette of red tissue. If only the mucosa is involved, then the prolapse is relatively small and shows radiating folds all the way around. If the entire bowel wall is involved, the prolapse is larger and is covered by concentrically circular folds. A rectal polyp is a soft mass that can be pedunculated or sessile. It is located inside the rectum and is not visible at the surface. Rectal polyps are soft and may be difficult to feel on rectal examination; usually they are diagnosed on proctoscopic examination.
4. The correct answer is (D) Anal fissure
An anal fissure is a painful oval ulceration of the anal canal and is found most commonly in the midline posteriorly inside the rectum/anal canal. Inspection of the anus may show a swollen "sentinel" skin tag just below it, and gentle separation of the anal margins may reveal the lower edge of the fissure.
A pilonidal cyst is identified by the opening of a sinus tract on the skin. It is usually located in the midline superficial to the coccyx or the lower sacrum. There may be a small tuft of hair at the opening, and it may be surrounded by a halo of erythema. There is no discrete opening in this patient's scenario. An anorectal fistula is an inflammatory tract, which opens at one end of the anus or rectum and at the other end onto the skin surface or another viscus. The fistula opening is usually located around the anus, and there is typically no swollen skin tag visible to accompany it. A thrombosed external hemorrhoid results in an acute onset of pain, which is increased by sitting and by defecation. There is a tender, swollen, bluish, ovoid mass, which is visible at the anal margin. There are no areas of ulceration that are visible when you separate the anal margin.
5. The correct answer is (C) Benign prostatic hyperplasia
The patient's symptoms and physical exam are most consistent with benign prostatic hyperplasia. The affected prostate gland is symmetrically enlarged, smooth and firm, although slightly elastic. It may protrude more into the rectal lumen. The median sulcus may be obliterated as well. Further diagnostic tests may be required to rule out prostate cancer.
As described in this scenario, the prostate gland is enlarged, not normal in size, and, given the patient's urinary symptoms, this is not a normal prostate. In prostatitis, the patient has fever. The gland is very tender, swollen, firm, and warm to touch. This is not the case as described.
Prostate cancer is less likely in this scenario. Prostate cancer is suggested by an area of hardness in the gland. A discrete hard nodule may or may not be palpable. Further diagnostic studies are needed to make a diagnosis of cancer.
6. The correct answer is (D) Prostatitis
In acute prostatitis, the patient typically has fever and dysuria. The gland is very tender, swollen, firm, and warm to touch.
A normal prostate gland would be smooth, firm, and nontender to palpation. In benign prostatic hyperplasia, the affected prostate gland is symmetrically enlarged, smooth and firm, although slightly elastic. It may protrude more into the rectal lumen. The median sulcus may be obliterated as well. It is not usually tender to palpation. Prostate cancer is less likely in this scenario. Prostate cancer is suggested by an area of hardness in the gland. A discrete hard nodule may or may not be palpable. The nodule is not tender, and there is no accompanying fever. Further diagnostic studies are needed to make a diagnosis of cancer.
The Peripheral Vascular System Multiple Choice
1. The correct answer is (B) Acute arterial occlusion
The throwing of an embolism, or thrombosis, causes sudden symptoms associated with a cold, pale, pulseless extremity.
Artherosclerosis obliterans is incorrect. Generally it is preceded by episodic aching pain during exercise of the affected extremity. Resting causes the pain to abate within 1-3 minutes. Pulses are often weakened but can be found by Doppler. Deep venous thrombosis is also an incorrect response. Pain often develops gradually from the clot in the vein of the extremity. There is also swelling of the extremity, with local tenderness. Strength and reflexes are not affected. If the peripheral pulses are diminished it is due to the increase in tissue swelling; Doppler should still elicit pulses. Cellulitis is an infection of the superficial layer of skin on the extremities. This also develops slowly, and the systemic symptoms of malaise and fever are usually associated.
2. The correct answer is (D) Deep venous thrombosis
Deep venous thrombosis is from clot formation in the deep draining veins of the calves and thighs. It can cause an aching pain and swelling of the extremity. Cords, which are associated with more superficial thrombosis, are generally not felt.
Cellulitis is not a correct response. Since cellulitis is an infectious process of the skin, there is usually profound redness and warmth involved. Raynaud's disease generally occurs in the extremities due to spasm of the small arteries, leading to transient color changes and pain. Often pallor is followed by cyanosis and redness. There is no swelling of the extremities. Atherosclerosis obliterans is episodic muscular ischemia caused by exercise. In this case, the patient had exercised with no problems. There can also be local muscle fatigue and diminished pulses.
3. The correct answer is (B) Superficial thrombophlebitis
Superficial thrombophlebitis is caused by the clotting of superficial veins; it is often due to trauma. There is localized redness, swelling, warmth, and pain. It can be accompanied by fever.
Raynaud's disease is incorrect. Raynaud's generally occurs in the extremities due to spasm of the small arteries, leading to transient color changes and pain. Often pallor is followed by cyanosis and redness. There is no localized swelling, tenderness, or warmth. Superficial thrombophlebitis is also an incorrect response. The throwing of an embolism, or thrombosis, causes sudden symptoms associated with a cold, pale, pulseless extremity. There are no local areas of warmth or swelling. Cords cannot be palpated. Likewise, deep venous thrombosis is wrong. Deep venous thrombosis is from clot formation in the deep draining veins of the extremities. It can cause an aching pain and cause swelling of the extremity. Cords that are associated with more superficial thrombosis are generally not felt.
4. The correct answer is (C) Neuropathic ulcer
Neuropathic ulcers appear at areas of pressure points because the person affected is unable to perceive that there is pain in the area. The peripheral neuropathy accounts for the lack of pain and the occasional late diagnosis.
Arterial insufficiency ulcers are caused by a lack of arterial blood supply; so they tend to occur at the most distal areas, such as the toes. There is no callus formation surrounding them, and they are usually quite painful. The foot is usually pale when elevated and dusky when dependent. Venous insufficiency ulcers occur because of venous stagnation in the foot, leading to edema. Due to this, the ulcers generally occur at the ankle in the areas of edema. These ulcers tend to be located on skin with permanent color changes due to the accumulation of venous return. The ulcers, although not as painful as arterial ulcers, do generally hurt.
5. The correct answer is (A) Insufficiency ulcer
Ulcers from a decrease in arterial blood flow are often found at the distal portion of the extremities, such as the toes. The foot is generally red in color with no swelling. Pulses are often weak or absent.
Venous insufficiency ulcers occur because of venous stagnation in the foot, leading to edema. Due to this, the ulcers generally occur at the ankle in the areas of edema. These ulcers tend to be located on skin with permanent color changes due to the accumulation of venous return. The ulcers, although not as painful as arterial ulcers, do generally hurt. Arterial neuropathic ulcers are usually located in areas of pressure, such as the lateral side of the fifth digit and just proximal to the great toe on the plantar surface. There is generally callus formation surrounding the ulcer. These ulcers tend not to hurt because there is a lack of pain sensation from neuropathy.
6. The correct answer is (C) Lymphedema
Lymphedema is swelling in the extremities caused by blockage in lymphatic return. This obstruction is often due to tumor, trauma, inflammation; it is rarely infectious. The swelling includes the toes and often causes thickening of the skin. Ulcerations are rare. In this case, the damage to the lymph ducts occurred during surgery.
Pitting edema is always found bilaterally and is caused when interstitial fluid leaks from the vessels due to congestive heart disease, nephrotic syndrome, cirrhosis, or malnutrition. Pitting edema can also be caused by prolonged dependency of the lower extremities. There is no skin thickening and generally no ulcerations. The edema associated with chronic venous insufficiency is caused by insufficiency of the valves in the deep veins of the legs. The accumulated fluid is first soft and then hard. The edema can occur either in just one extremity or in both. Ulceration is common; thickening is usually limited to the area around the ankle.
7. The correct answer is (A) Pitting edema
Pitting edema is the result of an interstitial leak from the vessels due to hypervolemia or from a decrease in oncotic pressure of the fluid, allowing fluid to leave the vessels. In this case, probable cirrhosis of the liver leads to malnutrition, resulting in low albumin, which is causing the oncotic leak. The swelling in the extremities is always bilateral, with generally no skin thickening or ulcerations.
Chronic venous insufficiency is not a correct response. The edema associated with it results from insufficiency of the valves in the deep veins of the legs. Accumulated fluid is first soft and then hard. The edema can occur either in just one extremity or in both. Ulceration is common. Thickening is usually limited to the area around the ankle. Lymphedema is also incorrect. Lymphedema is swelling in the extremities due to blockage in lymphatic return. This obstruction is often due to tumor, trauma, inflammation, and, rarely, infections. The swelling includes the toes and often causes thickening of the skin. Ulcerations are rare.
The Musculoskeletal System Multiple Choice
1. The correct answer is (C) Gouty arthritis
Gouty arthritis usually occurs spontaneously, after a night in bed or a large meal. It results in swollen, red, warm, very tender joints. It is caused by an increase in crystals within the joint.
Rheumatoid arthritis generally develops slowly over time and is symmetrical, with multiple joints affected. Although the joints may be swollen and tender, they are usually neither red nor warm. There also tends to be generalized systemic complaints of fatigue, weight loss, fever, and weakness. This is believed to be autoimmune in origin. Degenerative joint disease generally also develops slowly, but not necessarily symmetrically. Joints are often tender but usually do not swell very much and are not red or warm. The disease is caused by degeneration in the cartilage of joints. Polymyalgia rheumatica can occur gradually or overnight. It generally affects the muscles surrounding the larger joints of the hips and shoulder. Muscles are tender, but there is no redness or warmth around the joint. This is also autoimmune in origin.
2. The correct answer is (D) Rotator cuff tear
Rotator cuff tear is often seen in people over 40 due to a sudden trauma or repeated impingement weakening the rotator cuff group. This often eventually leads to a complete tear. Weakness is common, as is atrophy of the muscles. With a complete tear, active abduction and flexion causes shoulder shrugging.
Although also often due to repetitive motion, rotator cuff tendonitis generally occurs in the athletic context of swimming or throwing. Activity aggravates the pain. Although there is weakness on exam with internal and external rotation, there is no shrugging of the shoulder with abduction or flexion. The tenderness in bicipital tendonitis centers over the long head of the bicipital tendon. There is generally no deficiency in range of motion, and there is no shrugging of the shoulder in abduction. Acrominoclavicular arthritis is an uncommon cause of shoulder pain and usually occurs when there is a direct blow to the shoulder girdle. Most tenderness is over the acromioclavicular joint. There is normal range of motion in the glenohumeral joint.
3. The correct answer is (B) Olecranon bursitis
Sudden and repetitive trauma often causes swelling and inflammation in the bursa. In this case, the repetitive injury of inappropriate weightlifting led to the accumulation of fluid in the bursa sac.
Arthritis is not a correct response. Degenerative joint disease is usually seen in older people and is caused by degeneration of the cartilage of the joint. Any swelling is felt in the grooves between the olecranon process and the epicondyles. The swelling usually feels boggy and is very tender. Although epicondylitis is also often associated with repetitive motion in sports, there is no swelling involved. There is, however, a great deal of point tenderness over the medial epicondyle in tennis elbow and golfer's elbow. Rheumatoid nodules are subcutaneous nodules, which develop along pressure points on the extensor surface of the ulna. They are firm and nontender. They are associated with longstanding rheumatoid arthritis or acute rheumatic fever.
4. The correct answer is (A) Ganglion
A ganglion is a growth along the tendon sheaths of joint capsules. Ganglions generally appear in young adults and are usually nontender. They are more prominent when the wrist is flexed.
Chronic tophaceous gout is an incorrect response. These swellings tend to occur along the joints of the phalanges and metacarpals. The tophaceous gout swellings are knobbylike and can ulcerate, discharging white chalklike material. The patient usually has a long history of gout. Acute rheumatoid arthritis is also incorrect. The swelling from rheumatoid arthritis tends to be symmetric between both hands, affecting the phalanges. There are no swellings along the dorsum of the wrist. There are generally also systemic symptoms of fatigue, weight loss, weakness, and fever. Choice (D) is incorrect as well. Herberden's nodes are boney overgrowths located on the dorsal lateral surface of the distal interphalangeal areas. They are usually hard but not painful. These are generally found in the elderly who have had degenerative joint disease for many years.
5. The correct answer is (A) Cervical sprain
A cervical sprain is often associated with an injury such as occurs in a motor vehicle accident, heavy lifting, or impact against the neck. There is local tenderness over the cervical muscles and a decreased range of motion of the neck.
Although muscle ache is often associated with tenderness over the neck, there is usually no precipitating injury. Often this pain is from postural problems while typing or studying. Neck pain with dermatomal radiation is often associated with severe injury that causes a herniation of the disc. The affected patient complains about pain radiating down his arm. He will often have decreased reflexes in the tendons of the affected arm and a dermatomal pattern of decreased sensation. Often coughing or straining will increase the pain. Neck pain from spinal stenosis can cause severe pain to the neck radiating to the arms and trunk. Often there will be weakness or paralysis in the arms or legs. At the most extreme, there can be loss of sensation. Coughing or straining will also worsen symptoms.
6. The correct answer is (C) Back pain from metastatic disease
Back pain from metastatic disease occurs even when the patient is at rest. It generally does not radiate, and the patient has normal reflexes, strength, and sensation. Often there is point tenderness where the metastatic disease is located. The pain in this patient most likely represents breast cancer metastasis.
Usually mechanical back pain causes symptoms of aching in the back during activity, and it is relieved with rest. Radicular back pain is caused by pressure against the spinal root, usually through a herniated disc. Pain originates in the lumbar area of the back but radiates down one or both legs. Often there is weakness in the affected extremities and decreased sensation. There are often decreased reflexes and a positive finding on straight leg raise. Often there is a history of trauma to the back. Although the type of back pain associated with spinal stenosis is common in the elderly, it generally causes more pain with walking; flexing the spine improves the symptoms. Spinal stenosis does cause loss of muscle strength and hyporeflexia. In severe cases, there can be loss of bowel or bladder function. Spinal stenosis is usually caused by severe degenerative disease narrowing the spinal canal.
The Nervous System
1. The correct answer is (C) Stuporous
A stuporous patient only responds to painful stimuli such as a sternal rub or the pinching of a tendon. When the painful stimulus is removed, he becomes unresponsive again.
A lethargic patient awakens to conversation, answers questions, and then returns to sleep. An obtunded patient often must be shaken to respond. He often looks confused and gives slow answers. A comatose patient will not respond to any external stimuli and will remain in an unarousable state.
Corns are thickened skin, which are caused by pressure against the foot. They occur most commonly on the lateral side of the fifth toe and between the fourth and fifth toes. Callus formations also occur at pressure points but at places where the skin is normally thick. Calluses are not painful and are usually located around the heel or over the plantar surface just proximal to the great toe. Neuropathic ulcers also develop at pressure points usually due to a lack of sensation. Although often deep and infected, they are not painful. They are usually red and warm and sometimes drain serosanguinous fluid.
2. The correct answer is (B) Postural (orthostatic) hypotension
Orthostatic hypotension can often be due to hypovolemia, which in this case is from vomiting and diarrhea. It generally occurs upon standing up after being in a recumbent position.
Vasodepressor syncope is generally precipitated by a strong emotional response, such as fear or pain. Usually it occurs when a person is already sitting or standing and is often accompanied by a feeling of weakness or sweating beforehand. In order for a cardiac arrhythmia to cause syncope, the heart rate must be generally less than 40 or greater than 180 bpm. It is usually associated with known cardiac disease. An hysterical faint is usually a symbolic expression of an unacceptable idea through the body language of fainting. It is usually seen in people with hysterical personality traits.
3. The correct answer is (C) Generalized tonic clonic (grand mal) seizure
Patients who experience a grand mal seizure often lose consciousness suddenly, with a stiffening of the body. This is often followed by the clonic jerking of the muscles. Tongue biting and urinary incontinence are often noted. The patient will then have a pronounced postictal state of confusion and drowsiness.
In a simple partial seizure, the patient remains fully conscious of his surroundings and is not drowsy after the seizure. The patient can often have tonic clonic movements, but only on one side of the body. A complex partial seizure often begins with symptoms similar to those of the simple partial seizure, which can also cause impairment in consciousness. Often automatisms, such as chewing or lips smacking, will occur. The patient may remember the beginning of his seizure. An absence seizure is generally a sudden brief lapse of consciousness accompanied by staring or movements of the lips or hands. Generally, this lasts for less than 10 seconds and is followed by no postictal state.
4. The correct answer is (A) Sensory ataxia
Sensory ataxia is associated with loss of position of the feet and legs often due to peripheral neuropathies such as those associated with diabetes. The gait is generally wide based and unsteady. The patients usually will throw their feet down heavily forward and outward. They must also watch the ground for guidance and usually cannot stand steady with their feet together (positive Rhomberg sign).
Cerebellar ataxia is usually associated with diseases that affect the cerebellum, such as alcoholism and stroke. Patients also have a wide staggering gait, but they cannot stay steady with their eyes opened or closed. Watching the ground does not help them walk. Parkinsonian gait is associated with basal ganglia defects from Parkinson's disease. Often the posture is stooped, with the head forward and the knees and hips flexed. The patient has difficulty starting to walk; while walking, the steps are short and shuffling. Steppage gait is associated with damage to the lower motor neurons, such as a herniated disc against a lumbar nerve root. The person lifts her foot high and slaps it to the floor, appearing as if she were trying to climb. She cannot walk on her heels.
5. The correct answer is (B) Postural tremors
Postural tremors occur when a person is holding the affected part of his body in a postural position. These tremors are often associated with hyperthyroidism, anxiety, and benign familial essential tremors, such as is the case here. Intentional movement can either worsen or improve the tremors.
Although resting tremors are present at rest and decrease with voluntary movement, they tend to have slow, fine pill rolling of the fingers. These tremors are often associated with Parkinson's disease. Intention tremors are absent at rest and occur with activity. The tremors often worsen when the hands get closer to their intended target. This is associated with cerebellar dysfunction, such as in alcoholism and multiple sclerosis. Athetosis is a movement disorder characterized more by slow writhing movements of the hands rather than tremor-like motion. It often also affects the face and distal extremities. It is associated with diseases such as cerebral palsy.
6. The correct answer is (C) Anterior horn cells
In anterior horn cell disease, there is both weakness and atrophy in a focal or segmental pattern. Sensation remains intact, while reflexes are decreased. When seen in childhood, the problem is often polio; in older adults, it is often amyotrophic lateral sclerosis (Lou Gehrig's disease). Fasciculations in the muscle fibers are often felt and seen.
Although in spinal root disease there is weakness in the muscle groups and decreased reflexes, there is also sensory deficits in the corresponding dermatomes. Spinal root disease is often caused by a herniated disc from trauma. In neuromuscular junction disease, there can be weakness in the muscles but usually this occurs after the muscles have been used for an extended time. This process is known as fatigability. The sensation also remains intact in the dermatomes, and the reflexes are normal. Myasthenia gravis is an example of neuromuscular junction disease. When muscle fibers are affected, there is pronounced weakness in the muscles, but sensation remains intact. Reflexes can be normal or decreased. Muscular dystrophy is an example of this type of disorder. Muscle fasciculations are rare.
7. The correct answer is (D) Schizophrenia
Schizophrenia often starts suddenly in young adults with strong family history of mental health problems. Delusions, hallucinations, disorganized speech, disorganized behavior, and negative symptoms (flat affect, lack of interest or drive) are often present. In this case, the young woman has delusions (winning the Nobel Prize as a college student), hallucinations (apparent when she is seen having conversations with herself), disorganized speech (with shifting of ideas and clanging speech), and disorganized behavior (wearing clothes backwards).
People with major depression generally can express their thoughts coherently and do fairly well with proverbs. Usually they seem sad and complain about feelings of worthlessness and fatigue. They often have problems with eating and sleeping. Sometimes they have thoughts of hurting or killing themselves. Those people with bipolar disorder often have alternating feelings of depression and elation. They can have delusions or fantasies about themselves, but again they usually can express their thoughts coherently. Often they have pressured speech, but usually they do not repeat phrases. People with generalized anxiety disorder often worry about several different areas of their lives (e.g., money, relationships, work, etc.). They can feel fatigued and act restless, but they generally are coherent in thought and speech.
8. The correct answer is (B) Delirium
The hallmark of delirium is that it occurs acutely. The course can be fluctuating, and the level of consciousness is disturbed. The patient can become somnolent, as in this case, or agitated. Illusions and hallucinations are common. Patients are often disoriented to place and time but not to person. Metabolic changes, poisonings, sepsis, and delirium tremens are causes. This episode probably began as a urinary tract infection that became uroseptic.
A psychotic reaction to major depression is not a correct response. Although hallucinations are common in psychotic reactions, there is usually an underlying mental health disorder such as depression or mania. lso psychosis does not cause somnolence. Dementia is also incorrect. Dementia is a slowly progressive change in mental status over months to years. The level of consciousness is generally unaffected. Hallucinations and delusions may occur. Until late stages, patients are usually oriented to person, place, and time. The most common causes are Alzheimer's disease and multi-infarct dementia.
Chapter 17 Assessing Children
Case Study: Abdominal Pain
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