conviction of having a serious illness despite repeated evidence to the

Conviction of having a serious illness despite

This preview shows page 82 - 84 out of 96 pages.

conviction of having a serious illness, despite repeated evidence to the contrary. Even when presented with definitive evidence, these patients remain convinced that they are ill. Patience, compassion, regularly scheduled appointments, and collaboration with a psychiatrist may be effective in treating these patients. Since this patient is not depressed, suicidal, or homicidal, hospitalization (choice A) is not indicated. She should probably go to talk to a psychiatrist, and make regularly scheduled appointments to see you. A "second opinion" (choice B) is not necessary in this case of hypochondriasis because she has already seen 6 other physicians, and does not seem to have a breast mass. She needs regularly scheduled appointments, and she should see a psychiatrist. Because the clinical breast examination, mammogram, ultrasound, and CT scan were unremarkable, a CT scan (choice C) and a fine needle aspiration (choice D) are not necessary. This patient most likely has hypochondriasis and usually a thorough medical work-up is enough, but unnecessary procedures should be discouraged. Also, a FNA is used when there is a discrete mass, and there is nothing in this case. A 17-year-old girl is brought into your clinic by her mother, who is concerned that " she really just doesn't look well to me." Her medical history is unremarkable except for irregular menses since menarche at age 16. She has no surgical history, does not take any medications, and has no known drug allergies.
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You ask her mother to leave the room and ask the patient about sexual activity, tobacco, drug, and alcohol use, which she denies. There are no problems at home. She is in her senior year of high school and is doing very well, participating in track and field as well as maintaining a 3.9 average. She is planning to attend college and hopes to become a lawyer. Review of systems is negative except for weight loss, but the patient states, "I have always been a little too heavy. This last year I just lost my baby fat, that's all." She acknowledges running several miles a day as part of her training regimen for the track team. The patient denies any problem with eating, although she feels as though "I could still stand to lose a few pounds. My face is way too chubby." When you speak alone with her mother, you elicit that the patient is very strict about what foods she considers appropriate to eat and insists on preparing her own meals. Her temperature is 37.0 C (98.6 F), blood pressure is 105/68 mm Hg, pulse is 59/min, and respirations are 12/min. She weighs 44.5 kg (98 lb) and is 5'5". The body-mass index (BMI) calculates to 16 kg/m2. She is an alert, cooperative, thin young female in no distress. Her hair appears dry and brittle. However, the remainder of the physical examination is unremarkable. Laboratory studies, including biochemical profile, erythrocyte sedimentation rate (ESR,) complete blood count, and thyroid studies are within normal limits. The most appropriate next step in the management of this patient is to A. begin treatment with megestrol (Megace) to stimulate appetite B. begin treatment with oral contraceptives to regulate her menses
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  • Spring '14
  • Major depressive disorder

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