Usmle Step 3 Review Course Northwestern Medical Review-PDF Free Download

USMLE Step 3 Review Course Northwestern Medical Review

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USMLE Step 3 Review Course Online Video Course General Medicine A. Akhter, MD Poisoning Carbon Monoxide Carbon Monoxide poisoning occurs mostly in context poorly functioning heating systems, improperly vented fuel-burning devices (eg, kerosene heaters, charcoal grills, camping stoves, gasoline-powered electrical generators), and motor vehicles operating in poorly ventilated areas. Commonest ...



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Usually after drinking bootleg whiskey comes with visual disturbance
PE mydriasis hyperemia of optic disc
Lab Anion gap metabolic acidosis osmolal gap serum methanol level
Treatment Fomepizole antidote of choice IV
Alternative ethanol hemodialysis for severe toxicity 50 mg dL
Ethylene Glycol
Secondary to ingestion of antifreeze solution
Clinical Feature confusion tachypnea
Lab Anion gap metabolic acidosis urine test has oxalate crystal osmolal gap
Treatment same as methanol poisoning
Organophosphate insecticide
History of insecticide spray or a farmer coming from work
Complaints Abdominal pain diarrhea vomitting Shortness of breath
Physical Exam Miosis constricted pupil sweating wheezing
Treatment Wash the skin with soap and water
Atropine I V decreases sweating and wheezing
Pralidoxime 2 PAM I V specific antidote
Salicylate Poisoning
Nausea vomiting tinnitus tachypnea
Lab metabolic acidosis and respiratory alkalosis
Treatment Alkalinize urine by sodium bicarbonate I V
Hemodialysis for severe acidosis or altered mental status
Black Widow Spider Bite
Clinical Feature generalized muscular pain muscle spasm rigidity
Treatment parenteral narcotic for pain
Muscle relaxant methocabomol I M or I V for spasm
Calcium gluconate I V for rigidity
Rarely antivenin I V
Brown Recluse Spider Bite
Clinical Feature extensive local necrosis and hemolytic reaction may not be felt
at all or only as a pinprick
Lesion is small 2cm
o supportive measures dress the wound tetanus toxoid rest analgesics and
close follow up
Large massive necrotic lesion 2cm
o Treat with systemic corticosteroids 5 7 days
Opioid Intoxication
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Morphine Codeine Heroin Meperidine Methadone Oxycontin
Clinical Feature Euphoria drowsiness constricted pupil hypotension
bradycardia hypothermia and respiratory arrest
Seizure likely secondary to Meperidine especially in patients with renal failure
due to accumulation of metabolite nor meperidine
Duration of effect of Heroin 3 5 hr
Methadone intoxication may last 48 72 hrs
Most opioids are detectable on routine urine toxicology except Methadone newer
Fentanyl derivative
Treatment Naloxone 0 4 mg to 2 mg IV
Duration of effect of Naloxone is 2 3 hr
Repeated dosage required for patients intoxicated with Methadone
Patient should be observed at least 3 hours after the last dose of Naloxone
Poisoning Specific Antidote
Beta Blocker Glucagon
Acetaminophen Acetylcysteine
Carbon Monoxide 100 Oxygen
Benzodiazepine Flumazenil
Cyanide Nitrite Amyl nitrite Sodium nitrite
Digoxin Fab antibody fragment digibind
Opiates Naloxone
Iron Defuroxamine
Methanol ethylene glycol Fomepizole
Methemoglobinemia Methylene blue
Snake Bite
Venom could be cytolytic Rattle snake other Pit Vipers most common in USA
Neurotoxic Coral Snake
Cytolytic venom causes tissue destruction by digestion and hemorrhage due to
hemolysis and destruction of endothelial lining of blood vessels
Manifestation local pain redness swelling extravasation of blood nausea
vomiting hypotension coagulopathy may also occur
Neurotoxic venom causes ptosis diplopia dysphagia respiratory paralysis
Management
Immobilize the patient and bitten part in neutral position
Avoid manipulation of bitten area
Avoid any stimulant
Do not apply ice
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Do not apply tourniquet
Incision and suction by unskilled people is not justified in view of small amount
of venom that can be recovered
Transport pt to nearest facility
In hospital
Labs CBC Chem 7 CPK PT PTT Urine for myoglobin
If no local or systemic signs and symptoms and coagulation profile normal
discharge home in 12 hours
Specific Antidote
Pit Vipers Rattle Snake Crotalid antivenin CroFab Slow IV in normal saline
antihistamine keep epinephrine ready in case of anaphylactic reaction
Oxygen IV fluid Asses need for Tetanus toxoid antibiotic Augmentin
Coral Snake For specific antivenin call the regional poison center they help you
to locate antisera Horse serum based antivenom is available in USA
Adequacy of treatment is indicated by clinical signs and symptoms and rate of
swelling slows down also follow up the coagulation profile
DO NOT FORGET ABC
Control airway oxygen pulse oximeter intubation
If trauma first immobilize cervical spine with hard collar until you r o fracture
or instability
IV line cardiac monitor check cardiac monitor
Vitals stabilize it if hypotensive start Inravenous normal saline vasopressors
dopamine norepinephrine
Order finger stick CBC Chem 7 LFT ammonia ABG PT PTT type and
cross match blood cx UA urine toxicology blood toxicology screen alcohol
level serum osmolality urine osmolality cardiac enzyme portable chest x ray
EKG Foley catheter
IV thiamine 50 dextrose 50 cc IV Naloxone IV
Flumazenil IV if the suspicion of Benzodiazepine is high Routine use is not
advisable since it can cause Seizure
Exam look for signs of head trauma cirrhosis sepsis rash of meningococcemia
Look at the pupils
o Small but reactive narcotic overdose or metabolic encephalopathy
o Dilated fixed unilateral r o uncal herniation hyperventilation
mannitol IV dexamethasone IV urgent neurosurgery consult CT head
o Dilated fixed bilateral drug intoxication with methyl alcohol or severe
anoxic encephalopathy
If patient is febrile vancomycin and gentamycin IV
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Follow up labs If serum osmolality high and anion gap metabolic acidosis
hyperemia of optic disc Fomepizole
If vitals stable CT head non diagnostic Lumbar puncture
Send CSF for cell count cx glucose protein
Still undiagnosed EEG to diagnose non convulsive status epilepticus
encephalitis encephalopathy
CCS Case Coma
Location Emergency Room
CC Unresponsive
Vitals B P is 120 60mm of Hg Pulse is 100 minute Temperature is 990F
RR is10 12 minute
History of Present Illness
30 year old male brought by his girlfriend as was found unresponsive in his apartment A
bottle of liquor 75 empty and couple of bottles of medicines of anxiety were empty
Past Medical History Alcohol Abuse Anxiety Depression
Personal History Smokes one pack of cigarette daily Smoked Marijuana five years ago
Drinks alcohol everyday No history of IV drug abuse
Allergy Unknown
Family History Unknown
DO NOT FORGET ABC
Airway oral To maintain the patency of airway
Oxygen continuous
Pulse oximeter
Cardiac monitor
Intravenous access
Intravenous fluid Normal saline
Finger stick glucose
Pulse oximeter should have oxygen saturation more than 90 if it is less than 90
Intubation
Note If history is suggestive of some poisoning and you are planning to do gastric
Lavage in a comatose patient always intubate prior to gastric Lavage Gastric Lavage is
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not being used routinely except if you have clear history of ingestion of life threatening
amount of toxin and patient presents within 60 minutes of ingestion of the substance if
they want you to do gastric Lavage history will be patient took this medication this
many pill while arguing with a family member or friend who brought the patient to the
hospital If patient is conscious you can perform gastric Lavage without intubation But
if patient is unconscious first intubate before gastric Lavage
Again order battery of test and procedure
CBC Chem8 Liver Function Test LFT Ammonia Arterial Blood Gas ABG PT
PTT Type and cross match blood c s Cardiac enzyme Blood toxicology screen
Blood Alcohol level Serum osmolality X ray chest AP Portable EKG Foley s catheter
U A Urine toxicology Urine Osmolality
After above orders Order the following in the same sequence
Thiamine therapy I V one time bolus Dextrose 50 in water I V stat
Naloxone I V one time bolus
Flumazenil I V one time bolus
Note Thiamine is give before the administration of Dextrose because if dextrose is
administered in a Thiamine deficient patient it can precipitate Wernicke s
Encephalopathy Usually thiamine deficiency occurs in Alcoholics
If patient becomes conscious after the administration of I V Naloxone suggest opiate
intoxication If this patient again becomes unconscious suggest long acting opiate
intoxication eg Methadone which will need multiple dosages of Naloxone I V
If patient becomes conscious after the administration of Flumazenil suggests
Benzodiazipine intoxication
Patient did not respond to above treatment If Urine toxicology result becomes available
and is positive for benzodiazepine this does not mean patient has benzodiazepine
toxicity since patient did not respond to Flumazenil Although benzodiazepine was
positive in urine because patient has history of anxiety and was on benzodiazepine
Scenario 1
If patient has hypotension and EKG shows Arrhythmia Prolonged PR QRS and QT
interval likely diagnosis is Tricyclic Antidepressant poisoning since patient has history
of depression and anxiety Order Sodium bicarbonate I V continuous
Check vitals if vitals remain stable order CT scan of the head If the scan report is
normal transfer the patient to the Intensive care unit
Follow up serum and urine toxicology to confirm the diagnosis of TCA poisoning
Scenario 2
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If patient has not responded to above cocktail look into the examination HEENT
finding dilated pupils hyperemia of optic disc check labs serum osmolality
Serum osmolality high check anion gap Anion gap 14 Anion gap metabolic
acidosis check U A normal No crystals most likely diagnosis Methanol
poisoning Start IV Fomepizole or Ethanol
Check vitals if vitals remain stable order CT scan of the head If the scan report is
normal transfer the patient to the Intensive care unit
Scenario 3
If patient has not responded to above cocktail look into the examination HEENT
finding Pupils are normal check labs serum osmolality Serum osmolality
high check anion gap Anion gap 14 Anion gap metabolic acidosis check U A
calcium oxalate crystals most likely diagnosis Ethylene Glycol anti freeze
poisoning Start IV Fomepizole or Ethanol
Check vitals if vitals remain stable order CT scan of the head If the scan report is
normal transfer the patient to the Intensive care unit
Scenario 4
If patient has not responded to above cocktail look into the examination HEENT
finding pupils are normal check labs serum osmolality Serum osmolality
high check anion gap Anion gap normal 12 2 check U A increased ketones
in the urine no crystals Order serum ketone Follow up the serum toxicology result
which tells you about isopropyl alcohol level most likely diagnosis Isopropyl
Alcohol poisoning Treatment is supportive continue above management
Check vitals if vitals remain stable order CT scan of the head If the scan report is
normal transfer the patient to the Intensive care unit
Primary Immune Deficiency
Common Variable Immune deficiency disease CVID
Abnormality in B cell function
Presents between one year to adulthood
When onset is in adulthood they may have underlying lymphoid malignancy
Presents with recurrent bacterial infection involving sinuses middle ear lung with
systemic spread
Treatment IVIG lifelong
Hyper IgE syndrome Job s syndrome
Recurrent skin and visceral hepatic renal pulmonary perianal abscess
Mostly secondary to staphylococcal infection
Elevated IgE level
DiGeorge Syndrome
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Secondary to deletion of chromosome 22q11 development of 3 and 4 pharyngeal
pouch gets affected causing anomaly of face thymus parathyroid and cardiac
structures
1 Absent T cells secondary to absence of thymus
2 Congenital heart disease
3 Hypocalcemia secondary to hypoparathyroidism
Characteristic facial appearance cleft palate small mouth low set ears short
palpebral fissure widened distance between the inner canthi telecanthous
Congenital heart disease Tetralogy of fallot Truncus arteriosus atrial and ventricular
septal defect
Hypocalcemia presents with tetany seizure
Treatment Bone marrow transplant
Wiscott Aldrich syndrome
Mix of immunoglobulin defect and T cell deficiency
Clinical Features Eczema develops during first year of life resembles atopic
dermatitis
Thrombocytopenia presenting with bleeding
Characteristic immunoglobulin pattern IgG normal IgM very low IgA and IgE
Prone to have infection with encapsulated organisms due to immunoglobulin defect
Increased incidence of non Hodgkin s lymphoma
Treatment Bone marrow transplant
If bone marrow transplant not feasible due to absence of HLA matched donor
splenectomy is the treatment of choice for patients with platelet count less than 50 000
IVIG every 3 to 4 weeks
Antibiotic prophylaxis Amoxicillin or Trimethoprim sulfamethoxazole daily
Severe combined immunodeficiency disease SCID
Absence of both cellular and humoral immunity
Usually symptoms starts in newborn period
Classical symptoms are recurrent severe infection chronic diarrhea and failure to
Chronic mucocutaneous candidiasis is a common early finding
Attenuated vaccine such as OPV can cause severe infection
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Blood transfusion can cause graft versus host disease GVHD
Lab lymphopenia absolute lymphocyte count less than 2000 mm3 in a newborn is an
absolute indication for evaluation of SCID
Hypoglobulinemia
Impaired specific antibody response
Cutaneous anergy
Treatment Bone marrow transplant
Adenosine deaminase deficient SCID
Profound lymphopenia absolute lymphocyte count less than 500 mm3
Chondro osseous dysplasia of costochondral junction
Vertebral bodies reveal Rachitic Rosary rib cage
Chediack Higashi Syndrome
Phagocytic disorder Neutrophils contain abnormal Giant granules due to
inappropriate fusion of lysosomes and endosomes
Recurrent pyogenic infection
Partial oculocutaneous albinism
Neurologic abnormality Photophobia Nystagmus Peripheral neuropathy seizure
dysfunction of spinal tract and cerebellum
IgA deficiency
Most common primary immunodeficiency
Predominent immunoglobulin of nasal secretion is IgA
Most patients are asymptomatic but may develop recurrent sino pulmonary infection
recurrent gastrointestinal infection particularly giardia lamblia secretory IgA usually
binds with pathogens and toxins
Anaphylactic blood transfusion reaction
Ataxia Telangiectasia
Progressive cerebellar ataxia since the beginning of walking appear healthy for the
first year of life which slowly gets worst and by 10 12 years of age become
wheelchair bound
Ocular or facial Telangiectasia mostly appear when child is 3 5 year of age
Elevated alpha feto protein is found in more than 95 patients over the age of 8
Immunodeficiency Absent or low IgA and IgE level mostly develop sino pulmonary
infections
No effective treatment
Vitamin Deficiency
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Vitamin deficiency syndromes develop gradually symptoms are non specific and
physical exam is rarely helpful in early diagnosis
Some vitamins can be used efficaciously as drugs
o Vitamin A derivatives Treat cystic acne and skin wrinkles
o Niacin Treats hyperlipidemia
Vitamin A Deficiency
Important for normal retinal function wound healing and cell growth and
differentiation
Causes Fat malabsorption syndromes and mineral oil laxative abuse it occurs
commonly in the elderly and urban poor in the US
CLINICAL FEATURE Night blindness xerosis dryness of the conjunctiva
Bitot s spots Keratomalacia perforation endophthalmitis and blindness
Treatment Vitamin A 30 000 IU day x 1 week for early deficiency
Toxicity staining of the skin orange yellow and with hypervitaminosis dry scaly
skin hair loss mouth sores painful hyperostosis anorexia and vomitting early on
Late findings hypercalcemia increased ICP cirrhosis
Vitamin A derivatives also used to treat Cystic Acne and Skin wrinkles
remember however it is teratogenic therefore always do a pregnancy test in
females of child bearing age Topical use can increase the risk of skin cancer
Vitamin B1 Thiamine Deficiency
Causes alcoholic chronic dialysis
CLINICAL FEATURE
o Wet beriberi Symptoms are cardiovascular heart failure ascites edema
o Dry beriberi Symptoms are neurological both peripheral and central
o Wernicke s encephalopathy nystagmus ophthalmoplegia ataxia
change in mental status
o Korsakoff s psychosis confabulation and retrograde amnesia
Treatment large parenteral doses 50 100 mg day for first few days followed by
daily doses 5 10 mg day
Vitamin B2 Riboflavin Deficiency
Causes drugs phenothiazine tricyclic antidepressants
CLINICAL FEATURE Glossitis cheilosis angular stomatitis seborrheic
dermatitis weakness corneal vascularization and anemia
Treatment meat fish dairy or oral preparation of vitamin 5 15 mg day
Vitamin B6 Pyridoxine Deficiency
Causes patient on INH Penicillamine OCPs or alcoholism
CLINICAL FEATURE mouth soreness glossitis cheilosis if severe peripheral
neuropathy seizure
Treatment oral supplements 10 20 mg day typically given with INH
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Toxicity irreversible sensory neuropathy on high doses
Niacin Deficiency
Causes Historically it occurred when corn which is relatively deficient in niacin
was the major source of calories Today Alcoholism INH Carcinoid syndrome
CLINICAL FEATURE Pellagra 3D diarrhea dementia dermatitis and if
advanced even death
Treatment oral doses 10 150 mg day
It is also used to treat hyperlipidemia
Toxicity can be seen when treating hyperlipidemia Cutaneous flushing to avoid
pre treat with Aspirin 325 mg day
Vitamin C Deficiency
Potent antioxidant also required for the synthesis of collagen
Increases absorption of Iron
Decreases effect of Warfarin
Causes hyperoxaluria
CLINICAL FEATURE Scurvy Due to impaired collagen synthesis Symptoms
are bleeding gum ecchymoses petechiae hyperkeratosis impaired wound
healing weakness joint pain and swelling neuropathy
Treatment Ascorbic acid 300 1000 mg day
Toxicity gastric irritation flatulence and diarrhea at high doses Fecal occult
blood could be false negatives and urine glucose could be false positives
Vitamin D Deficiency
Causes insufficient sun exposure malnutrition malabsorption rickets
anticonvulsants often seen in institutionalized elderly
CLINICAL FEATURE osteomalacia osteopenia
Treatment Sunlight Vitamin D supplements
Vitamin E Deficiency
Functions as an antioxidant protecting cell membranes and other structures from
the attack of free radicals
Investigational use to prevent Alzheimer s
CLINICAL FEATURE Hemolysis Ataxia Myopathy
o Increases effect of Warfarin Causes Vitamin K deficiency
Treatment oral doses of 100 400 units day
Toxicity nausea diarrhea and may cause bleeding in those taking coumadin
Factor II VII IX X protein C and S are vitamin K dependent clotting factors
Causes poor diet malabsorption broad spectrum antibiotics
CLINICAL FEATURE bleeding from venipuncture site
Treatment Subcutaneous vitamin K supplement
Selenium Deficiency of Selenium can cause Congestive Heart Failure
Chromium Deficiency of chromium can cause Insulin Resistance
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Zinc Deficiency of Zinc can cause delayed wound healing
Complications of modern day hobbies
Tanning beds Addictive can cause basal cell carcinoma especially in women who
are taking OCP or Antihistamine
Hair Removal Eflornithine ornithine decarboxylase inhibitor is FDA approved
for the use of abnormal facial hair
Complication Reversible Anemia Leucopenia
Laser Hair removal Side effect could be hypo pigmentation flare up of Acne and
End of 1st Hour
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Medicine Use Comment
St John s Wort Depression Avoid with SSRI
Activates Cytochrome P450system
and so decreases the plasma
concentration of Theophylline
Cyclosporine Indinavir Warfarin
Digoxin Simvastatin Oral
contraceptive
Saw Palmetto Benign Prostatic Hypertrophy Improves urinary symptoms
Does not decrease Prostate size or
May cause Hypertension
Ginseng Fatigue Diabetes Hypertension Hypoglycemia
Witch Hazel Hemorrhoids and Acne External use has no side effect
Ginkgo Dementia Avoid with NSAID Warfarin
Heparin increased risk of bleeding
Glucosamine Osteoarthritis
Creatine Athletes to increase Avoid in renal failure
performance
DHEA Anti aging agent sexual
enhancer depression
Ephedra Sympathomimetic used for Hypertension arrhythmia stroke
weight loss stimulant
Licorice Used in chewing gum and Inhibits 11 hydroxy steroid
chewing tobacco dehydrogenase which converts
Cortisol to Cortisone if Cortisol
level is high it will stimulate
Aldosterone receptors Patient will
have symptoms of primary
hyperaldosteronism like
hypertension hypokalemia and
metabolic alkalosis
Black Cohosh Active ingredient Side effect Nausea vomiting and
Also known as Phytoestrogens estrogen like hypotension
Actaea racemosa L effect helps in menopausal
Cimicifuga symptoms Caution when used patient taking
racemosa anticoagulant and antihypertensive
Black Snakeroot Isoferulic acid aspirin like medication Patient having
Bugwort effect helps in rheumatic pain undiagnosed uterine bleeding
Rattle Root
Rattle Weed
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Geriatrics
Changes in physiologic function with age
Organ System Age Related Decline in Function
Special Senses Presbyopia
Lens opacification
Decreased hearing
Decreased taste and smell
Cardiovascular Impaired intrinsic contractile function
Decreased conductivity
Decreased ventricular filling
Increased systolic blood pressure
Impaired baroreceptor function
Respiratory Decreased lung elasticity
Decreased maximal breathing capacity
Decreased mucous clearance
Decreased arterial PO2
Gastrointestinal Decreased esophageal colonic motility
Renal Decreased Glomerular filtration rate
Immune Decreased cell mediated immunity
Decreased T cell number
Increased T suppressor cells
Decreased T helper cells
Loss of memory cells
Decline in Ab titers to known Ag
Increased autoimmunity
Endocrine Decreased hormonal responses to stimulation
Impaired glucose tolerance
Decreased Androgens and Estrogens
Impaired norepinephrine response
Autonomic Nervous Impaired response to fluid deprivation
Decline in baroreceptor reflex
Increased susceptibility to hypothermia
Neurologic Decreased vibratory sense
Decreased proprioception
Musculoskeletal Decreased muscle mass
Sensory Impairment
o The most common cause of hearing loss is sensorineural Presbycusis
o Screening test Hearing Handicap Inventory for the Elderly Screening
Version HHIE S whispered voice test audioscopy
o Hearing loss leads to social isolation and depression
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o The most common causes of age related visual impairment Age related
macular degeneration AMD cataracts glaucoma
o AMD leading cause of blindness in those 65
o Screening test Snellen or Jaeger eye chart
Q 87 yo M living in an assisted living home recently became socially isolated no longer
visiting with friends eating in the common dining room or watching television Vitals are all
stable All labs WNL Geriatric depression score 1 5 low risk for depression What to do
Q An 81 year old man is evaluated for a 6 month history of a constant buzzing sound in both
ears The noise interferes with reading watching television and sleep He denies headache
vertigo or sinus pain Depression screening results are negative Vitals are stable PE normal
What to do
The prevalence of dementia doubles every 5 years after age 60 by the age of 85
about 30 50 of individuals have some degree of impairment
Short term memory is important to inquire about finding out whether patients
have difficulty forgetting to take medications forgetting appointments or getting
lost while driving
Screening test Folstein Mini Mental State Examination 24 30 is significant
Level of education can affect performance
Identification of dementia early can identify potentially reversible causes like
folate B12 deficiency syphilis hypothyroidism depression
Treatment for dementia
o Donepezil a centrally acting cholinesterase inhibitor modestly improves
cognition global function and psychiatric symptoms
o Memantine is recommended for patients for moderate to severe
Alzheimer s
o Vitamin E may help slow progression
Q A 78 year old F concerned that she is losing her memory visits her primary care
physician accompanied by her daughter The daughter confirms that the patient is forgetful
and does not recall conversations that have occurred in recent days The patient appears
cheerful physical exam well groomed and friendly Which of the following is the most
appropriate next step in the assessment of this patient s cognitive impairment
Depression
A simple 2 question screen has shown 96 sensitivity for detecting major
depression in the general population and even higher in those 65
o In the last month have you often been bothered by feeling sad depressed
or hopeless
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