This is a very high yield text which teach how to improve their diagnostic and problem-solving skills as they work through sixty high-yield clinical cases. The new edition is well updated with new Case Correlations feature which highlights differential diagnosis and related cases in the book. If the link is not responding, kindly inform us through comments section. We will fixed it soon. Click to download pdf. For those who are new to this book, a new exciting feature of Case Files Internal Medicine 5th Edition PDF includes Case Correlations which presents 25 challenging questions to the readers at the end of each chapter to evaluate the knowledge of the readers.
A highly recommended book for those training in internal medicine. We have uploaded a genuine PDF ebook copy of this book to our online file repository so that you can enjoy a blazing-fast downloading experience. We highly encourage our visitors to purchase original books from the respected publishers. The risk of further episodes of major depression increases with the number of prior episodes, the occurrence of residual symptoms of depression between episodes, and any comorbid psychiatric or chronic medical illnesses.
The treatment that was successful for prior episodes of major depression has a higher likelihood of achieving remission in future episodes. Selective serotonin reuptake inhibitors—bupropion, venlafaxine, and mirtazapine—are all first-line treatment options for major depressive disorder.
Practice guidelines for the treatment of major depressive disorder. Stoudemire A. Clinical psychiatry for medical students, 3rd ed. He denies that he currently uses drugs or alcohol, although he reports that he occasionally smoked marijuana in the past. On a mental status examination the patient is noted to be dirty and disheveled, with poor hygiene. He appears somewhat nervous in his surroundings and paces around the examination room, always with his back to a wall.
His speech is of normal rate, rhythm, and tone. His thought processes are tangential, and loose associations are occasionally noted. His thought content is positive for delusions and auditory hallucinations. He denies any suicidal or homicidal ideation. What conditions are important to rule out before a diagnosis can be made? Should this patient be hospitalized? For at least 1 year he has experienced delusions and auditory hallucinations. He has become socially isolated and dysfunctional as a result of these symptoms.
He denies current drug use or medical problems. A mental status examination shows several abnormalities. Disturbances in grooming, hygiene, and behavior paranoia are noted, and he has a flat affect. His thought processes are occasionally loose, and he reports auditory hallucinations and delusions. Important conditions to rule out: To make a diagnosis of schizophrenia, substance abuse and general medical conditions must be ruled out. In addition, schizoaffective disorders and mood disorders must also be excluded.
He clearly is unable to care for himself because he listens to voices and acts on their instructions in such a manner that makes him behave dangerously ie, sitting in the middle of a busy street. Be able to diagnose schizophrenia in a patient.
Understand that other conditions must be ruled out before such a diagnosis can be made. Understand admission criteria and know when a patient should be admitted. Considerations This patient demonstrates the two main diagnostic criteria for schizophrenia: delusions thinks people are not who they say they are and auditory hallucinations.
See Table for diagnostic requirements. The hallucinations have several characteristics seen in schizophrenic psychoses—several voices are speaking to each other about the patient and there are command hallucinations. On a mental status examination the patient shows loosening of thought associations as well.
He has had the disorder for at least 1 year. He denies mood symptoms, drug abuse, and medical problems, although of course these issues would need to be further investigated by obtaining a more complete history, performing a physical examination, and ordering the appropriate laboratory tests.
Delusions Hallucinations Disorganized speech Disorganized or catatonic behavior Negative symptoms. Delusions: Fixed, false beliefs that remain despite evidence to the contrary and are not culturally sanctioned. Flat affect: The absence of a noticeable emotional state eg, no facial expression. Ideas of reference: False beliefs that, for example, a television or radio performer, a song, or a newspaper article is referring to oneself.
Loose associations: Thoughts that are not connected to one another or illogical answers to questions. Negative symptoms of schizophrenia: Anhedonia, poor attention, low motivation, and a flat affect. Positive symptoms of schizophrenia: Ideas of reference, paranoia, delusions, and hallucinations. Tangentiality: Thoughts may be connected to each other although the patient does not come back to the original point or answer the question.
The average age of onset is 15 to 25 years in men and 25 to 35 years in women. Women tend to have better outcomes than men. Fifty percent of schizophrenics attempt suicide; those with depressive symptoms, a younger age of onset, and a higher level of premorbid functioning are at increased risk. The etiology is not known. There are five subtypes of schizophrenia: 1. Paranoid: Characterized by preoccupation with one or more delusions or frequent auditory hallucinations 2.
Disorganized: Usually characterized by disorganized speech and behavior and a flat or inappropriate affect 3. Undifferentiated: Manifested by two or more of the following: delusions, hallucinations, disorganized speech, grossly disorganized behavior, and negative symptoms; however, the patient does not meet the criteria for the other types of this disorder.
Continuing evidence of disturbance is indicated by the presence of negative symptoms or two or more criteria in an attenuated form. Differential Diagnosis Most important and immediate in the differential diagnosis are medical conditions characterized by psychotic symptoms such as deliria, dementias, severe hypothyroidism, and hypercalcemia. Alcohol and illicit drugs, either during intoxication hallucinogens, cocaine or withdrawal alcohol, benzodiazepines , can produce psychotic symptoms.
In fact, symptoms of phencyclidine intoxication can appear identical to those of schizophrenia. A thorough history of substance use, a physical examination including the measurement of vital signs, a determination of blood alcohol level, and a urine toxicology screening reveal substance use as a causal factor in most cases.
A careful examination of the medications a patient is taking, including over-the- counter and herbal supplements, is also important, as many medications eg, steroids and anticholinergics can cause psychotic states. Patients are frequently poor historians given their psychotic symptoms, and so gathering information from other sources such as prior records, family members, or significant others is imperative because a complete history can help clarify the issue.
Table highlights these differences. The above distinctions are important not only for the diagnosis but also in determining the treatment and the prognosis. In general, mood disorder with psychotic features has a better prognosis than schizoaffective disorder, which has a better prognosis than schizophrenia. Although clozapine is beneficial, especially in treatment-resistant schizophrenia, the posssibility that it may cause agranulocytosis prevents it from being a first-line drug.
Although typical medications adequately treat the positive symptoms of schizophrenia, they can worsen or actually cause negative symptoms. Atypical medications appear to treat the positive symptoms at least as well as the older medications and also treat the negative symptoms.
Older antipsychotics also have a higher likelihood of causing unwanted side effects, namely, extrapyramidal symptoms dystonias, parkinsonian symptoms, and akathisia , hyperprolactinemia leading to impotence, amenorrhea, or gynecomastia , and tardive dyskinesia. Acute symptoms such as dystonic reactions and parkinsonian symptoms can be managed by reducing the dose or adding an anticholinergic drug such as benztropine. Unfortunately, tardive dyskinesia is usually a permanent condition and can be both disfiguring and disabling.
Neuroleptic malignant syndrome NMS can occur with any antipsychotic at any time during treatment. The treatment is intended to provide supportive management, although dantrolene and bromocriptine may also be beneficial. Comprehension Questions [2. Auditory hallucinations Belief that one has the power of an alien species Catatonic symptoms Depression Inappropriate affect Match the most likely diagnosis A through D with the following case scenarios questions [2.
Major depression with psychotic features Schizoaffective disorder Schizophrenia Psychosis secondary to a general medical condition [2. He is certain that the government is involved because they often communicate with him through a microchip they have implanted in his brain. Although he feels frustrated at being taken advantage of, he denies any significant depressive symptoms and is often able to enjoy playing cards with his peers at the group home. He reports difficulty sleeping, a lb weight loss, frequent crying spells, and profound guilt over surviving her.
For the last several days, he has been convinced that his body is literally decaying. She insists that he has professed his intentions to marry her through messages in his song lyrics. She has written numerous letters to him and loitered around his home, resulting in several arrests. Although all these symptoms can be seen in various psychotic disorders, the presence of a bizarre delusion is the most specific to schizophrenia.
Only one psychotic symptom is needed to diagnose schizophrenia if there are bizarre delusions, auditory hallucinations commenting on the patient, or two or more voices speaking to each other. The most likely diagnosis for this man is schizophrenia. He has been suffering from psychotic symptoms including delusions and auditory hallucinations for more than 6 months.
Although he may have brief periods of depressed mood, he does not have a history of major mood disorder. The most likely diagnosis for this man is major depression with psychotic features. Significant depression and neurovegetative symptoms are present, as well as delusions and auditory and visual hallucinations. Although he has mood symptoms and psychotic symptoms, his history is consistent with major depression because his mood symptoms preceded his psychotic symptoms.
The most likely diagnosis for this woman is schizoaffective disorder. She describes a 6-month history of ideas of reference, delusions, and auditory hallucinations. In addition, she has had clear manic symptoms for the past month, including an elevated mood, a decreased need for sleep, increased energy, increased goal-directed activities, and talkativeness.
Although she has symptoms consistent with schizophrenia, she has had a significant episode of mood disorder during her psychotic illness. Her psychotic symptoms, which preceded and occurred in the absence of mood symptoms, make primary mood disorder mania with psychotic features less likely. Schizophrenia is a chronic illness, the diagnosis requiring more than 6 months of psychotic symptoms.
Negative symptoms of schizophrenia include a flat affect, anhedonia, poor motivation, and poor attention. Overall, major depression with psychotic features has a better prognosis than schizoaffective disorder, which has a better prognosis than schizophrenia. Clozapine is beneficial, especially in treatment-resistant schizophrenia, but has a significant adverse effect in that it causes agranulocytosis. Neuroleptic malignant syndrome can occur with any antipsychotic at any time during treatment.
The treatment should be supportive, possibly including dantrolene or bromocriptine. Practice guidelines for treatment of schizophrenia. She has been to the emergency department twice in the past 2 weeks, convinced that she is having a heart attack.
However, the results of all her physical and laboratory examinations have been within normal limits. Since that time she has had similar episodes once or twice a day, every day.
As a result she finds herself worrying almost constantly about when she is going to have another attack. She denies having any other symptoms. Her only medical problem is a 1-year history of hypothyroidism for which she takes levothyroxine Synthroid.
She has been to the emergency department several times with the same symptoms, and no physical problems were found. The episodes have occurred once or twice a day for several months, and nothing in particular seems to precipitate them.
The patient spends a lot of time between attacks worrying about when she is going to have another attack. The episodes last approximately 15 minutes. The patient denies alcohol or drug abuse, and her only medical problem is hypothyroidism. Next diagnostic step: Obtain a thyroid profile and look for elevated levels of thyroid hormone, which if present could explain her symptoms.
Be able to correctly diagnose panic disorder in a patient. Be aware that medical illnesses or some substances can cause panic attacks. Understand how to rule out a medical illness or substance use issue by requesting the appropriate laboratory studies. Considerations This woman presents with classic symptoms of a panic attack. They are short-lived in duration, lasting about 15 minutes per episode. The patient spends a lot of time in between the attacks worrying about having another attack, a classic feature of the disease.
The patient does not seem to have any symptoms of any other psychiatric disorder. She denies drug or alcohol use other than the occasional use of alcohol which should be carefully quantified.
She has hypothyroidism that is being treated with levothyroxine, which has been known to cause panic attacks when the dose is too high; thyroid studies should be used to rule out this possibility. If the thyroxine level is too high, the diagnosis will be substanceinduced anxiety disorder and not anxiety disorder secondary to hyperthyroidism, as might be considered. The use of benzodiazepine should be discontinued after the first several weeks. Cognitive behavioral therapy can also be used.
If the patient has an anxiety disorder due to a substance thyroid medication , the dose should be decreased and the panic symptoms should remit.
These situations include being outside the home alone, being in a crowd, being on a bridge, or traveling on a bus, train, or automobile. Panic attack: A period of intense fear lasting for a discrete period of time, associated with at least four of the symptoms listed in Table The criteria for panic disorder are denoted in Table Clinical Approach Attacks may vary from several a day to only a few during the course of an entire year.
Palpitations 2. Sweating 3. Trembling 4. Shortness of breath 5. Feeling of choking 6. Chest pain 7. Nausea 8. Dizziness 9. Derealization or depersonalization Fear of losing control or going crazy Fear of dying Numbness or tingling Recurrent, unexpected panic attacks 2. Attacks followed by 1 month of one of the following: concerns about having additional attacks, worry about the consequences of attacks, or a change in behavior as a result of attacks 3. Attacks are not due to substance abuse, to medication, or to a general medical condition 4.
Attacks are not better accounted for by another mental illness 5. It requires that at least one panic attack be followed by concern about another attack, fear of the implications of the attack, or a change in behavior related to the attack. The DSM-IV has established two diagnostic criteria for this disorder: panic disorders with agoraphobia anxiety about being in places or situations from which escape would be difficult and without agoraphobia.
It is theorized that agoraphobia stems from the fear of having a panic attack in a place from which escape would prove difficult. Typically, the first panic attack an individual experiences is spontaneous; however, it can also follow excitement, exertion, or an emotional event.
The attack begins within a minute period of rapidly intensifying symptoms extreme fear or a sense of impending doom and may last up to 20 to 30 minutes. Patients with agoraphobia avoid being in situations where obtaining help from friends or loved ones would be difficult.
These individuals typically need to be accompanied when traveling on busy streets or in enclosed areas tunnels, elevators. Severely affected individuals do not even leave their own homes. In the general population the lifetime prevalence rates of panic disorder ranges from 1. The mean age of presentation is about 25 years, with women being two or three times more likely to be affected than men.
Approximately one third of patients with panic disorder also have agoraphobia. Differential Diagnosis At the top of the differential diagnosis list for panic disorder are the numerous medical conditions that can cause panic attacks. Table 3. Intoxication caused by amphetamines, cocaine, or hallucinogens and by withdrawal from alcohol or other sedative-hypnotic agents can mimic panic disorder.
Medications such as steroids, anticholinergics, and theophylline are also well known to produce anxiety. Obtaining a thorough history including details of alcohol and substance use and performing a physical examination can usually clarify the issue. Except for the elevated blood pressure and pulse rate found in anxious states, no abnormalities are seen on examination.
Distinguishing panic disorder from other anxiety disorders can often be confusing. Panic attacks can be seen in many other anxiety states, as well as in depression. In fact, major depressive disorder has a high rate of comorbidity with panic disorder. This condition is distinct from other anxiety disorders, where panic attacks are the result of exposure to a certain cue.
For example, a car backfiring might provoke a panic attack in a patient with posttraumatic stress disorder, or being near a dog might provoke a panic attack in someone with a specific phobia to dogs.
The other important aspect to remember is that in panic disorder the fear is actually of having an attack, not of a specific situation contamination in the case of obsessive-compulsive disorder or performance in the case of social phobia or of a number of activities as in generalized anxiety disorder.
Treatment Antidepressants such as selective serotonin reuptake inhibitors SSRIs , tricyclic antidepressants, and monoamine oxidase inhibitors are highly effective in treating panic disorder. As in depression, a significant therapeutic effect may not be seen for several weeks. Treatment with a benzodiazepine may be needed on a short-term basis to provide more immediate relief.
Given the addictive potential of benzodiazepines, as well as the significant comorbidity of alcohol abuse in panic disorder, the goal should be to use as small a dose for as short a period of time as possible, with the intention of discontinuing this medication once the antidepressant reaches full effect.
Cognitive-behavioral therapy can be helpful, especially in panic disorder with agoraphobia, as it specifically addresses the restrictions on lifestyle present in individuals with this condition. Comprehension Questions [3. Although he does not have difficulty with one-on-one situations, when giving a lecture he becomes extremely anxious, worrying that he will be humiliated.
He relates one episode in which he was forced to speak at the last minute, which resulted in his experiencing panic, shaking, abdominal cramps, and a fear that he would defecate on himself. Because of this problem, he has been held back from promotion at his place of business. Which of the following is the most likely diagnosis?
For the past 5 years she has had increasing difficulty traveling far from home. She is convinced that if she drives too far from home, she will have an attack and not be able to obtain help. On finding herself at a significant elevation, she has severe anxiety symptoms such as trembling, lightheadedness, numbness and tingling, and a fear of dying.
He is convinced that he is experiencing angina attacks consisting of nervousness, sweating, palpitations, flushing, and numbness in his hands and lasting approximately 5 minutes.
He is anxious about having these symptoms and, despite negative results from a cardiology workup, remains certain that he will suffer a heart attack. His behavior and lifestyle have not been otherwise affected. Generalized anxiety disorder Panic disorder Social phobia Specific phobia Answers [3.
The most likely diagnosis for this man is social phobia. Although he suffers from panic attacks, they are not unprovoked as in panic disorder because they occur in response to public speaking. His fear is not of having further attacks but rather of being embarrassed or humiliated. This woman most likely has panic disorder with agoraphobia. She experiences recurrent spontaneous panic attacks and between attacks worries about having further attacks. She avoids driving away from her home for fear of being unable to obtain help in the event of an attack.
Specific phobia is the most likely diagnosis for this woman. Although she has panic attacks, they are not unexpected and result from being in a high place.
Her fears are actually of a situation heights rather than of having further panic attacks. The most likely diagnosis for this man is panic disorder without agoraphobia. He displays characteristic features of panic attacks, such as recurrent episodes of anxiety associated with physical symptoms. These episodes are spontaneous, and he worries about the consequences of having an additional attack, namely, a myocardial infarction.
Any medical conditions, medications, or substance abuse that can cause panic attacks should be ruled out. Major depressive disorder is commonly seen in patients with panic disorder. Selective serotonin reuptake inhibitors or other antidepressants are used in the pharmacologic treatment of panic disorder. If benzodiazepines are also administered, they should be used in as low a dose and for as short a time as possible. Treatment guidelines for panic disorder.
New York: McGraw-Hill. She has never visited a psychiatrist before and does not remember ever feeling this depressed for this long before. She states that she has no medical problems that she is aware of and that she takes no medication.
Her family history is positive for a history of schizophrenia in one maternal aunt. On a mental status examination the patient appears depressed and tired, although she has a normal range of affect. Her thought processes are linear and logical. She is not suicidal or homicidal and does not report hallucinations or delusions.
Her thyroid gland is diffusely enlarged but not painful. Her heart has a regular rate and rhythm. She has coarse, brittle hair but no rashes. She has never had these symptoms before. The results of the rest of her mental status examination are normal. Her physical examination is notable for a diffusely enlarged thyroid gland.
Next diagnostic step: Obtain thyroid studies for this patient, including determinations of thyrotropin TSH , triiodothyronine, and thyroxine levels. To recognize mood disorder occurring secondary to a general medical condition.
To be able to use the most likely diagnosis for this patient to guide the laboratory examination required for a patient with suspected hypothyroidism. A weight gain is observed in patients with atypical major depression, but this condition is usually accompanied by an increase in appetite.
At times the clinical features of hypothyroidism are evident Figure An enlarged thyroid is not seen in patients with major depression but is a clue that guides the specific laboratory examinations chosen in this case. It can resemble either an episode of depression depressed mood or decreased pleasure or an episode of mania elevated or irritable mood. The history, the physical examination, or the laboratory findings must demonstrate a causal physiologic relationship between the medical illness and the change in mood.
Facial appearance puffy eyes and thickened skin of a man with hypothyroidism. Reproduced, with permission, from Fauci A, et al. Principles of internal medicine, 15th ed. The mood episode also should not occur only during a delirium.
Differential Diagnosis The differential diagnosis for mood disorder due to a general medical condition is large given the numerous medical and neurologic conditions that can cause depression or another mood state.
Table lists many of them. Also important in this differential diagnosis are substance-induced mood disorders caused not only by alcohol and illicit drugs in intoxication and in withdrawal but also by a vast number of medications. See Table for a partial list of medications that can cause depressive symptoms. Making a distinction between primary psychiatric and secondary induced mood disorder can sometimes be difficult, especially because stressors such as medical illnesses themselves can trigger episodes of both major depression and mania.
Treatment The treatment of mood disorder due to a general medical condition entails addressing the underlying medical condition first, if possible, and obtaining improvement in the symptoms. The Case Files series is an award-winning learning system proven to improve shelf-exam scores and clerkship performance.
Unlike other books on the market, this series helps students learn in the context of real patients instead of simply memorizing. Case Files Psychiatry teaches students how to improve their diagnostic and problem-solving skills as they work through sixty high-yield clinical cases. Each case includes a complete discussion, clinical pearls, references, and USMLE-style review questions with answers.
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