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NBME 21 Answers

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submitted by neonem(599),
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hTe araslc oiciuintmrt necert si 1 fo 3 tenpnocosm of ctmioiunrit erelfx rhe(ot 2 era frmo ntnieop arruiltce ofaintmor nda rlrbecae toer.x)c Salcra ctim eecrnt = -24SS nsialp orcd ellve nvtlriega fmor eravtln ithew tmetra in eth lcvePi esevnr, erislpnsbeo orf rdbalde natcicotron vai hte rccoegilhni vernse hi(nkt it csat no eth M3 rtocreep in het rebldda sro)u.dre?t fI uoy soel sehet esnvre (i.e. in vlpice ,atcurr)ef wlil rutels ni rlfooewv t.ieniocncnne

submitted by yotsubato(1120),
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eWll sahtt a raylle drecu awy ot csreen orf r.ioe..dpenss

champagnesupernova3  There's really no other way to say it without using euphemisms +4  
drdoom  You can’t rule out suicidal thoughts via inference. +  
drdoom  LAWYER: Did you ask the patient if she was suicidal? DOCTOR: Well, um, no, not exactly — but, I mean, she seemed okay .. +  
drdoom  LAWYER: So, a patient walks into your office, you suspect post partum depression — a diagnosis with known suicide risk — and you didn't ask if she was suicidal? +  
drdoom  DOCTOR: gulp +  
beetbox  @drdoom wow ok now this will stick to me forever. Always ask your patient so I can avoid lawsuits! +1  

NBME tends to focus on these rules for ethics questions: 1) ALWAYS acknowledge the pt's problem, distress, situation, etc. 2) NEVER ask the pt to lie 3) NEVER be a dick. The answer may sound robotic, but should never be mean. In this case, there's nothing more robotic than going directly from "I'm concerned" to "Have you considered suicide?" 4) NEVER refer the patient to another resource (in this case, the nurse, but could also be risk management, therapist, etc.) 5) COMMUNICATE with other clinicians/experts, etc. to resolve issues. Basically instead of referring the patient, you go to the resource yourself.

+/- anjum(23),

submitted by consuela_salon(27),
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wtha I got romf iths :eqitosnu REEVN %(99 of eht t)iem freer a epatnti to see nayone

madojo  I was convinced this one was the exception, but guess not, NEVER REFER! +  

submitted by neonem(599),
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ishT si a osapmttupr modo itbcnsaredu, a rteypt omonmc osrdedir ttha hsa to ahve na tones nitihw 4 wkees fo lrieyedv to eb demret as schu. atrutopsmP eblsu is eht ostm d,mil wthi a 558-0% iedencicn tear rep( AF ),2810 uayulsl elosvesr niwhit 10 dsya nad tartentem si olyn ovierpptus btu deen ot plou-wlof to esssas rof isplsebo rapmustopt dn.sseorepi tpoPumrsta eisednrops = 5%1-10 ,rtea heradiecctraz yb rseeedspd f,tfeca tanex,yi opro tritnonoccaen orf gratere tnha 2 eekws dna desen ot eb tteread /w BTC + SSR.I I kitnh teh uosqtine si itngtge at neercsgin for hist adn a lpyaotnleit eorm rlibaeotpmc ,mcantcolpiio spmatoturp shsyio.cps

thisisfine   Found this difficult because FA characterizes "thoughts of harming baby or self" as postpartum psychosis - which is super rare, and doesn't fit this case. Also, CBT is first line treatment for postpartum depression - so I still like the offer to refer to a therapist as the best choice. +11  
d_holles  Same @thisisfine. +2  
chandlerbas  i see what youre saying but we should make sure that the mother is alive for us to refer to a therapist. remember if shes willing to harm herself most likely also willing to harm the the little cutie asking for suicidal thoughts screens for progression to post partum psychosis with the aim to prevent the sentinel event: harm to the baby +  

submitted by drzed(277),
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PCGSESAI taricrie: )1( leiengf wevweeodher,m/peyl )(2 flia/grbuteiitity,ira 3() aon,ainedh )(4 fuiyiltcfd s,gnleeip ()5 I" leef "t.yli.u,g. rof a doipre of 6 keswe = meste hte trrcieia rof a edirpevsse eo,pesid dan seicn hsit swa in teh tpos rauptm edpo,ir aym eb sotp pumtar eerssipdon.

txeN etbs tspe si to srcene fro scaldiui nigoteahisot/htud of ahmrign eht .dlchi

submitted by bbr(35),
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"Has it mcoe sa a rupessir ot yuo owh adhr nrnageipt s?i Myan lopeep efel tath I." wya ton'd thkni sthi eiatadlvs rteih i,enlfesg and it dwluo ekam omseeno lefe yldba fi oyu aisd y"eh enorvyee lesda wtih shit it."hs oslA isht rnweas suefcdo no tprne,ngai eratrh nhta het yicarpsicht rnoeccn utpsta(rmop ird)osp.nsee

i"m cnoerencd ubtao owh bad y'uvoe nebe lgiefne y.lle"ta I kthni tshi esdo dweeonakcgl rhiet segnfel,i dan eosd owhs ttah teh hycpasini si ageeg.nd seY, sti tuB ta sit owrts, sit lltis emor eoptmlec htan hte eotrh esn.o

hoTug einqsout eabds on eyuor' nedigra ytls.e

drdoom  if a disease or syndrome has known risk of suicide, and you fail to assess for it, that's negligence brotha (“if you suspect, you must protect!”) +1  

submitted by an_improved_me(75),
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I altyotl teg ohw nsagki buota iec,siud dan gnaksi btauo ti tcdlyier si pttm.arion tuB my ocfusnoni is how stih ernasw onds'et evpriod any ogdo I tewn ihtw has" it moec sa a sup" baescue i deufrig taht lwudo dnle litfse nyleci ot hte ttpeina ngionep .up Wneh i lefe ti si riap,eatprpi i lowud hten gbnri pu eth ocietsvaonrn utoab -e,lhsfrma hgrnmia the a,bby adn .ediuics tuB as sti wetrnti, eht ptteian letsl uyo heyt efel h,tytis dan eht pinsyhcai vrye tcredyil says "wow uyo eelf yettpr i" Sesme eyvr vnisiteesni and ton ltaompi for tehsno uam.oomnctiicn

an_improved_me  Also, while i hear some people saying that making it seem like her problems aren't unique... well thats actually the point in a lot of conversations with patients-- making them feel not alone. I don't think i would feel great knowing that all other parents instantly love their kids, and have no problems taking care of them. Instead, I'd want to feel like whatever i'm feeling isn't abnormal and unnatural. "I feel like a bad parent"; "that's rare, most people feel like great parents" "thanks doc". Yikes. +1  

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