Behavioral Health


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/Y5_F1.jpg"}},{"insert":"\n\n"},{"insert":"As you walk towards the psychiatry clinic, the windows in the corridor show a gray and listless sky.\r\n\r\nFor once, you feel glad that you\u0027ll be spending the entire day indoors.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/Y5_F2.jpg"}},{"insert":"\n\n"},{"insert":"Your first patient comes in.\r\n\r\nGary is a 57-year-old civil engineer. He experienced an NSTEMI 3 weeks ago, which was medically managed. He has been on leave from his job since then.\n\nYou read the referral letter from the cardiology team. They think Gary has symptoms suggestive of depression, and would like you to review and manage as necessary.\n"}]}


{"ops":[{"insert":"You greet him: \u0022Nice to meet you, Gary! How are you today?\u0022\r\n\r\n\u0022I\u0027m not like my usual self, doctor,\u0022 he responds, and continues,\r\n\r\n\u0022Is it normal to feel so \u0027detached\u0027 after a heart attack? I know that I\u0027ll be cleared to go back to work soon, and I really love my job - but I just feel so disinterested now.\u0022\n\n\u0022Go on,\u0022 you encourage him.\r\n\r\n\u0022You know, I feel \u0027flat\u0027 all the time - that\u0027s the best term. I don\u0027t feel like eating, and even at night, I wake up over and over again and struggle to get back to sleep.\u0022\n\n\u0022Does anything make you feel better?\u0022 you ask.\r\n\r\n\u0022No, doctor. Nothing makes a difference. I\u0027ve always found pleasure with the simplest of things, but nothing interests me now. I can\u0027t bring myself to catch up with my friends, or even go out for a walk with my dog.\u0022\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/Y5_F4.jpg"}},{"insert":"\n\n"},{"insert":"You ask a few more questions.\r\n\r\nGary has not experienced similar symptoms in the past, and was healthy before his recent ischemic episode. Post-NSTEMI screening revealed elevated total cholesterol and LDL levels; he tested negative for both diabetes mellitus and hypertension.\r\n\r\nGary\u0027s cardiologist has given him the all clear to go back to work, and has also excluded a cardiac cause for his current symptoms.\n\nHe is currently on the following medications:\r\n\r\n- Aspirin 100 mg OD\r\n- Fosinopril sodium 10 mg OD\r\n- Metoprolol 100 mg BD\r\n- Atorvastatin 40 mg OD\r\n- Glyceryl trinitrate 400 mcg sublingual spray PRN\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/Y5_F5.jpg"}},{"insert":"\n\n"},{"insert":"Gary used to smoke heavily, to a total of 30 pack-years, but stopped doing so after the NSTEMI. He only drinks socially - at most, 1 to 2 units per week.\r\n\r\nHis father died at age 66, from a \u0022heart attack\u0022; his mother is still alive and healthy, at 85 years of age. He has a sister, aged 55 years, who is also healthy. There is no family history of mental disease.\n\nGary is divorced. He has a grown-up daughter who lives interstate. He currently lives alone, with his German Shepard, Max.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/Y5_F6.jpg"}},{"insert":"\n\n"},{"insert":"You move on to the mental state examination:\r\n\r\nGary appears well, but tired and pale. His speech, thought and behavior are appropriate. There is no psychomotor retardation, agitation or cognitive impairment. He lacks confidence and is worried about his ability to return to work. He denies suicidal ideation.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/Y5_F7.jpg"}},{"insert":"\n\n"},{"insert":"Proceeding to the physical examination, you note the following:\r\n\r\nHeight: 176 cm; weight: 90 kg; BMI: 29 kg\/m2, waist circumference: 112 cm. Pulse: 65 bpm, regular; BP: 135\/83 mmHg; respiratory rate: 15 per min.\r\n\r\nThe general examination is unremarkable, as is examination of the heart, lungs, and abdomen. No focal neurological signs are present.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/Y5_F8.jpg"}},{"insert":"\n\n"},{"insert":"Finishing off the examination, you look at the investigation results during his recent hospitalization.\r\n\r\nHis lipid profile shows mildly elevated LDL and total cholesterol levels. A fasting plasma glucose and HbA1c are both normal, as are liver and renal profiles, and serum TSH levels.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/Y5_F9.jpg"}},{"insert":"\n\n"},{"insert":"Applying the DSM-5 criteria, you realize that Gary has developed moderate depression. After an open discussion, he reluctantly agrees to undergo counseling.\r\n\r\nYou also appreciate that a pharmacological agent will likely be necessary as well.\n"}]}


{"ops":[{"insert":"What will you prescribe?\n"}]}
1. Amitriptyline
2. Sertraline
3. Venlafaxine