Eight weeks after having her first child, 32-year-old Mrs. Sadie Simmons
(G1P1) makes an appointment to see you. Since the birth of her baby,
Mrs. Simmons has been feeling emotionally drained.
Blood pressure 105/70 mmHg
Heart rate 76 beats per minute
Respiratory rate 14 breaths per minute.HISTORY—Include significant positives and negatives from the history
of present illness, past medical history, review of systems, and social
and family history.
Mrs. Sadie Simmons, a 32-year-old woman (G1P1), is 8 weeks postpartum. Since the birth of her healthy baby, she has been feeling
drained and has feelings of inadequacy regarding her ability to take
care of the child. Her parents and other relatives were helpful during
the pregnancy and shortly after she gave birth but have since returned
to their homes far away. Now few people visit and there is little support. Her husband is rarely at home to help; he is working a second
job for financial reasons and often comes home tired. Financially,
the couple is just making ends meet. There is a breakdown in communication between them and she thinks that her husband might
be feeling somewhat ignored and neglected since the baby was born.
Additionally, because of her weight gain during pregnancy, she feels
that her husband is probably finding her unattractive. Mrs. Simmons
admits to feeling tired all the time and has no energy. She has no
past history of psychiatric problems and has no thoughts of harming
the baby. She smokes three cigarettes daily and drinks two beers; she
does not use illicit drugs.
PHYSICAL EXAMINATION—Indicate only the pertinent positive and negative findings related to the patient’s chief complaint.
T = 97.7°F. BP = 105/70 mmHg. HR = 76 beats/min. RR =
The patient is a sad and tearful 32-year-old woman in NAD. She is
346 MASTERING THE USMLE STEP 2 CS
In order of likelihood, write no
more than five differential diagnoses for this patient’s current
1. postpartum depression
2. major depression
Immediate plans for no more
than five diagnostic studies.
3. TSH level.PPD may occur up to 1 year after the birth of a child. The new mother
lacks confidence and will have feelings of inadequacy regarding her
ability to take care of the newborn. Support systems that may have
been helpful earlier during the pregnancy or shortly after giving birth
(parents and relatives) may no longer be present in the household.
The mother will be fatigued, irritable, anxious, and sleep-deprived.
She may be tearful and sad. Occasionally, patients with PPD present
with symptoms of psychosis.
The household changes that occur with a new baby may affect the
relationship between husband and wife. The new mother may feel less
attractive to her husband. The husband may feel ignored and neglected
by the busy mother. Financial problems may further contribute to the
problems. The situation may be worse if the newborn is ill or premature. The risk of postpartum mood disturbance is increased in women
with prior episodes of major depressive disorder. The treatment of PPD
includes improving the support system available to the new mother and
enhancing communication between husband and wife. Medications are
often required in the treatment of this disorder. There is an increased
risk of infanticide with PPD, and the physician must screen for this
throughout the treatment period.
History-Taking Pearl: It is essential for the physician to ask the mother
about “ideas” regarding the infant. A depressed mother may be delusional and think the infant is ill and kill the infant to prevent it from
suffering in the future.
Patient Note Pearl: The differential diagnosis for postpartum depression includes major depressive disorder. The diagnostic workup may
include a TSH level. S.O.A.P charting
Expert Solution Preview
This patient is a 32-year-old woman who is 8 weeks postpartum and is experiencing emotional exhaustion and feelings of inadequacy after the birth of her baby. Her family support system is limited and her husband is often absent due to work. The patient has no prior history of psychiatric problems, but she is experiencing fatigue and has no energy. She smokes three cigarettes daily and drinks two beers but does not use illicit drugs. The patient is tearful and slightly overweight upon physical examination. The differential diagnosis includes postpartum depression and major depression.
1. What are common symptoms of postpartum depression?
Common symptoms of postpartum depression include feelings of sadness, anxiety, and irritability. The patient may experience fatigue, changes in appetite or sleeping patterns, and feelings of worthlessness or guilt. Some mothers may also have a decreased interest in their baby or have thoughts of harming themselves or their child.
2. What factors increase the risk of postpartum mood disturbance?
Women with prior episodes of major depressive disorder have an increased risk of postpartum mood disturbance. Additionally, financial problems, lack of social support, and a sick or premature newborn can also contribute to the development of postpartum depression.
3. How is postpartum depression treated?
Treatment of postpartum depression typically includes improving the support system available to the mother and enhancing communication between the mother and her partner. Medications may also be required as a part of treatment. It is important for the physician to screen for infanticide throughout the treatment period.
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