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NBME 20 Answers

nbme20/Block 2/Question#48 (49.7 difficulty score)
A sedentary 50-year-old man with hypertension ...
Antidepressant therapyπŸ”,πŸ“Ί
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 +10 
submitted by drzed(221),

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.

For the other cardiovascular factors, the only ones proven to improve mortality are statins, ACEi, BB (esp. carvedilol in heart failure), and spironolactone. None of those were answer choices, so MDD treatment was the best choice.




 +6 
submitted by strugglebus(165),
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sMot fo het tsp veauls reew orlan.m Dinkrgin w'tnsa gusr,ouoeat LDL asw il,dm BIM sha iefn. He ddi haev THN .uoghth heT isgtegb srik ctoafsr rae teh actf htat he ahd sredufef na MI and redtsat fugifesrn ervsee isoepndres (gwetih )ieastynox.s/l sT,uh eh is oerm ta skir ofr udcis.ei

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 +22  
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  



 +3 
submitted by mbourne(81),
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I iktnh ttah fi thye hda emtoishgn leki ttis"na pyeha"rt as an nsrawe c,oiech ew uwdol aehv na ugtrnema fro ttah sa ti duwlo ecsradee yotitmarl yb glnhpie rvtenpe NEORTAH trahe .kactta veer,How I nhitk atht riedneptssa-tan ahertpy lilw do a OLT to ventepr escui,id lehiw -moga3e atfty csaid lthha(ye sa hyet rea) 'ldoutwn do SA UHMC ot evrnpet a herat acatk.t

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er,Tfehoer eth wesran hodlsu eb atpiars-ndenset hpea.rty

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? +  
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) +  
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. +1  



 +0 
submitted by peteandplop(32),

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. +1