clar697
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A 55-year-old Native American woman who lives alone is brought to the emergency department after a minor fall in her home, which her mother witnessed. She tells her physician that her husband, who dies 6 weeks ago, comes to visit her every night and gives her guidance. She also states that he complains of being lonely and is waiting for her to join him. She states that her appetite and energy are normal and denies suicidal ideation. Physical examination shows a bruised arm and leg. Neurologic examination and CT scan of the head show no abnormalities. Which of the following is the most appropriate next step for the physician?
A) Ask her relatives if speaking to deceased loved ones is common to their culture
B) Ask her relatives is there is a family history of major depressive disorder with psychotic symptoms
C) Ask her relatives if there is a family history of schizophrenia
D) Order and EEG to determine of the patient is sleep-deprived
E) Order and MRI of the head
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| SpeaksSoftly
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A. is correct
In Native American cultures it is not uncommon for people to "communicate with the dead" ie. ancestors. This is considered a normal coping mechanism to grief given their cultural beliefs.
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| atulkalanuria
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are u serious or is the answer C ? maybe its A i have no idea speakssoftly dnt mind pls.
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| SpeaksSoftly
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If she had schizphrenia it would have been diagnosed before this time. There also needs to be more symptoms such as haluccinations of visual/audio and also a poor reality testing.
The fact that they case mentions her Native American culture is a hint that cultural influence needs to be considered when deciding if this is "normal" grieving.
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| drms
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I think it A too
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| yousefreda
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ummm .. isnt there visual and auditory hallucinations in the stem?...
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| yousefreda
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but interesting point about the native culture thing.. i never ran across that in kaplan, goljan , first aid or USMLEWORLD
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| levo_athena
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Could it be D?
"One of the symptoms of prolonged sleep deprivation is hallucinations (10). This could also be related to the I-function since it is the system that integrates the input from all other areas of the brain. If the neurons composing the I-function become too taxed then the picture in the head that the I-function produces may be more dissimilar from reality than usual. The neurons, under pressure to continue functioning but unable to perform optimally, create an image useful enough for a person to see most of his or her surroundings."
http://serendip.brynmawr.edu/exchange/node/1690
I excluded A coz the primary concern of the physician is to find the cause and prevent further bruising, and even if talking to deceased ones is a part of the culture, it isnt responsible the fall
I excluded B coz there were no features of depression....its normal grief response here.
C is a possibility due to the hallucinations, but there are no other features of schizophrenia mentioned.
I excluded E coz examination and CT scan were normal and in USMLE we should proceed with the least expensive options first 
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| hitesh
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I took this form and I marked D) Order and EEG to determine of the patient is sleep-deprived.
Though I think she's going through normal bereavement, her fall is of concern and steps should be taken to diagnose / prevent the cause of it.
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| SpeaksSoftly
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She bruised because she slipped and fell, not uncommon in an older person. The stem specifically mentions she is NA and in behaviorial one must take in cultural beliefs when determining if someone is using an accepted grieving response. This cannot be determined to be a audio and visual hallucination due to her cultural belief, NA often speak of "visions" and this is not considered a hallucination in psychology.
Always choose the cheapest method first. The correct answer is A, we had a question just like this in Behaviorial and many people got it wrong because they wanted to seek an organic cause. But when a demographic is mentioned in the stem then always consider culture.
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| DrNickSaysHello
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A - 100% sure. I've seen questions like this before.
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| DRFP
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A or C
But more then Likely A , 55 yr old with no info that they have memory problems so why would we not ask the Patient? Is it ok to disclose the patients condition to the Family?
The patient has a right to privacy.
I could be wrong here, Seems odd with HIPPA
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