Depression

A 40-year-old woman reports increasingly frequent and severe headaches during the past few months. She has had boutsof severe headaches since college, and episodic migraine was diagnosed a decade ago. She uses over-the-counter products(ibuprofen, ketoprofen, or aspirin) at the onset of an attack; if these fail to relieve symptoms, she takes hydrocodone/acetaminophen. During her worst attacks, she is typically forced to halt her activities, is unable to eat or drink, and mayvomit. For unresponsive or persistent (more than 24-hour) attacks, her husband drives her to the urgent care centerfor intravenous hydration, intramuscular promethazine, and additional doses of hydrocodone/acetaminophen. Accordingto the patient, a visit to the urgent care center “completely ruins our day.”

Q:Which patients with chronic respiratory disorders are good candidatesfor pulmonary rehabilitation? When is it a better option than surgery?

An 84-year-old woman with hypertension and type 2 diabetes mellitus isbrought to the emergency department (ED) after an episode of nearsyncope.When emergency medical service personnel initially assessed her,blood pressure was 96/60 mm Hg and heart rate was “slow”; however, shehad no symptoms.

An 84-year-old woman presents with a 3-year history of slowly progressivememory impairment accompanied by functional decline. Thepatient lives alone but has been receiving an increasing amount of support from her 2 daughters,who accompany her to the appointment. The daughters first noticed that their mother was havingtrouble driving. About a year ago, she started forgetting family recipes. She also left food cookingon the stove unattended and burned several pans. Currently, the daughters are providing mealsand transportation, assisting with housework, and doing their mother’s laundry. They have becomeincreasingly alarmed because she takes her medications only sporadically, despite the factthat they fill her pillboxes and call her regularly with reminders. Their chief concern is whether itis safe for their mother to continue to live alone.

A 45-year-old man has a history of migraine that started shortly after puberty. The headaches became more frequent andsevere 3 years ago, when the patient was promoted from metal worker to shift boss.

A39-year-old man is brought to theemergency department (ED)after his car struck a tree. He experienceda transient loss of consciousnesswith a 3-minute episode of retrogradeamnesia at the scene of the accident,despite wearing a seat belt andshoulder harness. He was disorientedto date and place.

A42-year-old man with a history of hypertension presents to an outpatientclinic with chest pain that began the day before, after he had worked outat his health club. The discomfort increases when he walks and worsenssomewhat with inspiration. No associated symptoms are noted. Results of aphysical examination are normal; no chest wall tenderness is evident. Becausecertain features of the presentation suggest an acute coronary syndrome, a12-lead ECG is obtained, which is shown here.

A 51-year-old man with hypertension, type 2 diabetes mellitus, and hypercholesterolemiapresents with a 1-hour history of substernal chest discomfort anddyspnea. He was given sublingual nitroglycerin in the emergency department,but his symptoms did not resolve.

An 84-year-old woman presents with a 3-year history of slowly progressivememory impairment accompanied by functional decline. Thepatient lives alone but has been receiving an increasing amount of support from her 2 daughters,who accompany her to the appointment. The daughters first noticed that their mother was havingtrouble driving. About a year ago, she started forgetting family recipes. She also left food cookingon the stove unattended and burned several pans. Currently, the daughters are providing mealsand transportation, assisting with housework, and doing their mother’s laundry. They have becomeincreasingly alarmed because she takes her medications only sporadically, despite the factthat they fill her pillboxes and call her regularly with reminders. Their chief concern is whether itis safe for their mother to continue to live alone.

For 3 days, a 42-year-old man has had episodic dullchest pain. The anterior precordial and retrosternalpain intensifies with inspiration and movement. He has nohistory of recent viral infection, hypertension, coronaryartery disease, cardiac surgery, diabetes mellitus, or hyperlipidemia.There is no family history of cardiovasculardisease.

A 76-year-old woman presents with chest pain-which she describes as“muscle tightness”- that began when she awoke in the morning. Thepain is constant, exacerbated by deep inspiration, and accompanied by asubjective sense of slight dyspnea; she rates its severity as 3 on a scale of1 to 10. She denies pain radiation, nausea, diaphoresis, palpitations, andlight-headedness. Her only cardiac risk factors are hypertension and a distanthistory of smoking.

A variety of clinical syndromes can cause T-wave inversions; these range from life-threatening events, such as acute coronary ischemia, pulmonary embolism, and CNS injury, to entirely benign conditions. Here: a discussion of conditions that can cause T-wave inversions in leads V1 through V4.

ROCHESTER, N.Y. -- Childhood obesity remained a focus of pediatrics during the year, along with concerns about safety, particularly the safety of psychiatric medications.

SAN ANTONIO -- The advent of endocrine therapy for breast cancer has raised a host of unanswered questions about who should get the new drugs, when, and what should be done about treatment side effects, researchers said here.

SILVER SPRING, Md. -- FDA advisers have recommended that a suicidality-risk black box warning on antidepressant drugs be extended from children and adolescents to cover adults in their middle 20s.

SILVER SPRING, Md. -- FDA advisers have recommended that a suicidality-risk black box warning on antidepressant drugs be extended from children and adolescents to cover adults in their middle 20s.

NEW YORK -- Inner-city children exposed in utero to high levels of a now-banned pesticide had significantly greater delays in mental and psychomotor development than peers with low prenatal exposure, investigators reported.

KUOPIO, Finland -- Antidepressants do not significantly reduce suicide, and those taking the drugs increase attempts, according to a large Finnish study. Yet there was a reduced overall mortality among suicidal patients taking antidepressants.

AARHUS, Denmark -- A first-time major mental illness can strike mothers with dramatic suddenness within three weeks of delivering a first child, researchers here reported.

BRISTOL, England -- For newly diagnosed depression patients, there may be a tell-tale taste test for selecting the right antidepressant.

BETHESDA, Md. -- Employers including depression screening with care management as a benefit could help improve workers' lives and the company's bottom line, researchers have concluded.

TORONTO -- For sleep-deprived new mothers, some planning and training may translate into nearly an extra hour of welcome shuteye, according to a small study here.

Although the estimates of prevalence vary, there is convincing evidence that patients with chronic obstructive pulmonary disease (COPD) are at increased risk for depression. Moreover, depression has been associated with diminished functional status, increased symptoms, and increased mortality in patients with COPD. Encouraging news comes from Nguyen and Carrieri-Kohlman, who report that a dyspnea self-management program that includes exercise can reduce both dyspnea and depressed mood in these patients.

ABSTRACT: Age-related changes that affect drug distribution, such as increased total body fat, decreased muscle mass, and decreased total body water, necessitate reduction in the dosage of water- and lipid-soluble agents. Because creatinine clearance declines with age, the dosage of agents that are excreted primarily by the kidney must also be lowered to prevent toxicity. Examples include aminoglycosides, fluoroquinolones, penicillins, procainamide, lithium, angiotensin-converting enzyme inhibitors, and digoxin. A good rule of thumb to follow until creatinine clearance can be calculated is to reduce the total dose by half in frail elderly persons or in those with established renal disease. Anticholinergic agents should be used with caution because they are associated with urinary retention, heart block, constipation, dry mouth, blurred vision, sedation, and acute or chronic confusion in elderly patients.

Increasing evidence demonstrates that adolescents with asthma are at greater risk for anxiety and depression. However, few studies have investigated the association of psychological disorders with asthma symptoms, an important factor in evaluating asthma treatment. Now the results of a large population-based study of adolescents with asthma confirm that anxiety and depression are highly associated with increased asthma symptoms.