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NBME 20 Answers

nbme20/Block 2/Question#48 (51.4 difficulty score)
A sedentary 50-year-old man with hypertension ...
Antidepressant therapyπŸ”,πŸ“Ί

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submitted by drzed(255),
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ristF cteesnne fo eth stem: he ash a we6-ke iysohtr ge..( tg2;& eskwe) fo rsiseedpno )(1, tyduilifcf nisgeple 2,)( egaifut )(,3 arddeecse apeeiptt )4,( dan roop yeroccotmen/mintnaor )5(

oFr a iinssdgoa fo D,MD you dene a 2 ewke throyis of 5 fo eht SPSIGEAC smopystm icwhh he tmese eh( is only ingsmis aiusicdl iinatode adn eeintstr ni )eaiittivcs. husT eh tesem eth anodcistgi tcairier ofr a ajrmo vsidepeser s,depoei chihw easnm atth matetnetr si ceaiddtni iwht an SS.IR

orF eth teohr svaralradoucic ct,orasf the lyon soen rvneop ot pmreiov loityamtr aer istt,nsa ,AiCE BB ps.(e oceldalriv in raeth )rlfi,eau and ieanlop.oorncst Nnoe fo osteh ewer asnwer ischoce, os DDM trtnemeat swa teh tebs .ciohec

submitted by strugglebus(172),
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sMto fo het spt suavle eewr lroa.nm knignrDi nwsat' asro,euougt LLD wsa ldm,i MIB ahs f.nie eH ddi ahev NTH .gtuhoh eTh bstggie rksi artscfo rae teh tafc thta he had efuefsdr an MI dna edtastr rfnfugsie evseer sdnepeirso ewi(hgt )olxiets.sya/n hTsu, he si oerm ta kisr fro diu.icse

sohaib111  Won't having an MI be a very big risk factor for another one ? And also if they wanted this answer (the anti-depressant), why would they just add that his LDL is inreasing in the last sentence... +14  
dbg  bc they're SOBs and DOBs +29  
doodimoodi  Yeah, recommended LDL in people with previous heart problem is < 100 jeez +1  
asingh  It is because of the timeframe of mortality is 2 yrs, everything else will affect later +5  
benny  mdd increase MI +  
benny  Type 2 diabetes and major depressive disorder (MDD) are independent contributors to cardiovascular disease and to an increased risk of myocardial infarction (MI). +  
drzed  None of the cardiovascular options would improve mortality (statins, ACEi, BB, spironolactone are the ones that have proven mortality benefit). So if they had put one of those, I think I would have chosen that, but given that the rest don't change mortality at all, I went with the antidepressants. +2  
ihatetesting  My thinking was that since he had an MI, a beta blocker would improve mortality, and propranolol is also used as an anxiolytic. +2  

submitted by mbourne(89),
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I kitnh htat if teyh hda niegtmsho ilke tinta"s rty"haep as na rnawse ,oechic we ludwo have an mteagnur for that sa ti odwul ecrdesea ttayrolmi yb henigpl nrvptee OTHREAN trhae ta.takc Hwevro,e I kitnh taht tnnte-pssdaiare yraehtp iwll od a LOT ot tpnvere i,icedsu heiwl 3egm-ao ayttf idsac ehal(yht sa they a)er twudlo'n od AS HMCU ot npervte a erhta kttaca.

Teh tsiunoqe si illbcsaya ai,gnks You" nac only srreebpic noe of sehet ot kpee shit ddue velia sa glon as eipos.bsl Wcihh eon lilw vhae the ebst enacch ta gniccamlhsoip t?tha"

oehTrere,f het sreanw lushod eb rieatdaespt-snn ye.hartp

bharatpillai  why antidepressant therapy though? there are not enough features given to suggest MDD. He's 56 years old, not an elderly single male so not at the highest "classical" population at risk of suicide? the question is so ambiguous... Given MI, wouldn't chronic alcoholic intake predispose him to dilated cardiomyopathy? +1  
neovanilla  I don't believe it's that he has MDD by the clinical definition. It's more that his QoL has probably changed drastically since the MI and MIs are strongly associated with decreased outlook on life, especially considering how common it is to get a second MI soon after the first. I don't know the stats on suicide post-MI, but helping the patient's depression to make him more pro-active to help himself prevent another MI would be better than "a diet high in omega 3 FAs" (at least, this was my justification, as mbourne was saying) +2  
drzed  First sentence of the stem: he has a 6-week history (e.g. >2 weeks) of depression (1), difficulty sleeping (2), fatigue (3), decreased appetite (4), and poor memory/concentration (5) For a diagnosis of MDD, you need a 2 week history of 5 of the SIGECAPS symptoms which he meets (he is only missing suicidal ideation and interest in activities). Thus he meets the diagnostic criteria for a major depressive episode, which means that treatment is indicated with an SSRI. +3  

submitted by peteandplop(37),

Can anyone explain why it's not anxiolytic? My logic was this dude has a bum ticker from previous MI, and his HR was 104/min--which can't be good for the old heart. I went w/a anxiolytic to bring his HR and anxiety under control.

Would an antidepressant do the same, thus, is it a better answer, or cover a wider range of symptoms?

underd0g  An SSRI would cover both depression and anxiety. +2