Patient Management Exercise for Psychosomatic Medicine

Jim is a 24-year-old man who was admitted to the hospital 4 days ago after sustaining numerous orthopedic injuries as the seat-belted front-seat passenger in a motor vehicle accident; you are asked to consult on his case during his hospitalization because he seems “depressed” and “uncooperative.”

Jim is a law student at a nearby university. On the evening of the accident, he and the other occupants in the car had been out to dinner to celebrate the end of the semester. Their car had been hit when another car crossed the median divider and collided head-on; airbags had deployed. Immediately after the collision Jim was awake at the scene, but transiently confused. He endorsed having had only “two beers” that evening, and blood alcohol levels upon arrival in the emergency room were consistent with that history. Paramedics had intubated him in the field to protect his airway, and from the emergency room he had been taken promptly to the operating room for debridement and repair of a compound left femoral fracture. He had been sedate for the first 24 hours postoperatively, but nursing notes and physician progress notes from postoperative days 2 and 3 describe periods of “restlessness” and “irritability” with shouting at staff to “leave me alone” when dressings needed to be changed, and other periods of being tearful and withdrawn. Postoperative pain had been managed initially with scheduled doses of morphine sulfate, but now that the patient could take medications and liquids orally, moderate doses of hydrocodone/acetaminophen (Vicodin) were being used with meperidine (Demerol) for breakthrough pain.

The patient guardedly allowed you to assess his situation. After promising him that you would not write anything in his medical records of a sensitive nature, you learned that the patient had been experiencing a recurrence of major depression in recent months; his first episode had been in college, and at that time he had seen a therapist for a few months and the episode resolved. His mother has had recurrent depression, successfully treated with selective serotonin reuptake inhibitors (SSRIs). Nine months ago when this episode began, he sought out a private psychiatrist and began paroxetine at 20 mg nightly; this was increased to 30 mg/day for the past 6 months. With this treatment, his symptoms of depression had been in remission before the motor vehicle accident.

He did not acknowledge that he was taking the antidepressant when he entered the hospital because he didn't want his friends to know that he was in treatment for depression. The paramedics and doctors in the ER had asked about his medications only in front of all his friends, with blatant disregard for what he viewed as private, confidential information. He shared with you that he had experienced a “discontinuation syndrome” reaction about 6 months ago, with similar feelings of restlessness, irritability, and emotional lability; on that occasion he had gone away for a 3-day weekend and neglected to bring along his medication.

Your bedside examination revealed that he had some minor attentional difficulties (easily distracted by alarm sounds from other patients' rooms), an affect that was constricted, and a mood that was “depressed and anxious” and that he was oriented to person and place but was off by 1 day for the date. He was somewhat slowed psychomotorically. His thought process was linear and well organized, and his thought content was notable for his despair at how an evening of fairly tame celebration had led to his orthopedic injuries and the risk of having his psychiatric history disclosed. His insight and judgment appeared to be acceptable.

Points awarded for correct and incorrect answers are scaled from best (3) to unhelpful but not harmful (0) to dangerous (−3).