A 30-year-old man who has had focal epilepsy for 15 years still experiences four to five episodes per month despite medication. He takes two anticonvulsants; his current medications are the ninth and tenth drugs he has tried. Repeated EEGs have shown a right temporal focus. He is on disability and lives with his parents. What is the next best step in management of this patient?

Correct Answer: C

Rationale: In the case presented, the next best step in managing the patient is option C: surgical evaluation. This choice is based on the patient's long history of focal epilepsy, multiple failed medication trials, persistent seizures, and identification of a specific focus on EEG. Surgical evaluation is indicated when a patient's seizures are refractory to medications and when there is a clear seizure focus that can be surgically resected, as in this case. Surgery offers the potential for seizure control or even cure in patients with drug-resistant focal epilepsy. Option A (addition of a third antiepileptic drug) may not be as effective given the patient's history of trying multiple medications without success. Adding more drugs may increase the risk of side effects without improving seizure control. Option B (substitution of a new drug) is also less likely to be successful since the patient has already tried multiple medications without adequate seizure control. Option D (transcranial magnetic stimulation) is not typically indicated in cases of drug-resistant focal epilepsy with a clear seizure focus on EEG. It is more commonly used for other neurological conditions. Educationally, this case highlights the importance of considering surgical evaluation in patients with drug-resistant focal epilepsy, particularly when there is a clear seizure focus identified on EEG despite multiple medication trials. It also emphasizes the need for a multidisciplinary approach involving neurologists, neurosurgeons, and epileptologists in the management of complex cases like this.

Correct Answer: B

Rationale: The correct answer is option B) Stay with her in the exam room. This intervention is the most helpful because it provides immediate support and reassurance to the patient who is experiencing extreme anxiety after a car accident. Being present with the patient can help calm her down, provide a sense of safety, and establish a therapeutic relationship. Option A) asking her to describe her feelings may not be as effective in this acute situation as the patient may not be able to articulate her feelings coherently due to distress. Option C) setting her up in a quiet exam room and giving her privacy may isolate the patient further, which could exacerbate her anxiety as she may feel abandoned or alone. Option D) encouraging her to remember what happened in the accident may trigger further distress or panic in the patient, worsening her anxiety symptoms. In an educational context, it is crucial for healthcare providers to understand the importance of immediate support and presence in managing acute anxiety in patients. Building trust and providing a safe environment are essential components of care in such situations.

Correct Answer: D

Rationale: The correct answer to the question is D) Palpitations. When an individual experiences stress and anxiety, the body's sympathetic nervous system is activated, leading to the release of stress hormones like adrenaline. This can cause an increase in heart rate, leading to palpitations. Palpitations are a common physiological response to stress and anxiety due to the activation of the "fight or flight" response. Option A) Urticaria is incorrect because urticaria refers to hives, which are not a typical physiological response to stress and anxiety. Option B) Light-headedness is incorrect as it is more commonly associated with issues like low blood pressure or dehydration rather than stress and anxiety. Option C) Sedation is incorrect as it refers to the calming or sleep-inducing effects of certain medications, which are not typically associated with the physiological response to stress and anxiety. In an educational context, understanding the physiological responses to stress and anxiety is crucial for healthcare professionals like nurses who may encounter patients experiencing these symptoms. Recognizing these signs can help in providing appropriate care and support to individuals dealing with stress and anxiety. It also highlights the importance of self-care and stress management techniques for healthcare workers to cope with the demands of their profession.

Correct Answer: C

Rationale: In major depression, patients often display signs of worthlessness, which is why option C is correct. Feelings of worthlessness are a common symptom of major depressive disorder, reflecting the negative self-perception and low self-esteem that characterize the condition. This symptom is a key diagnostic criterion used by mental health professionals to identify and assess depression in individuals. Option A, energy, is not typically associated with major depression. In fact, one of the hallmark symptoms of depression is fatigue and decreased energy levels, rather than increased energy. Option B, repetitive, compulsive behaviors, is more commonly associated with conditions like obsessive-compulsive disorder (OCD) rather than major depression. While some individuals with depression may also experience these behaviors, they are not as central to the diagnosis of major depression. Option D, visual hallucinations, are not a typical symptom of major depression. Hallucinations, if present, are more commonly associated with conditions like schizophrenia or substance-induced disorders rather than major depression. Educationally, understanding the specific symptoms of major depression is crucial for healthcare professionals, particularly those working in mental health settings. Recognizing and accurately identifying symptoms like worthlessness can aid in early diagnosis and appropriate treatment planning for individuals suffering from major depression. It is essential for medical professionals to be able to differentiate between symptoms of different mental health disorders to provide effective and targeted care for their patients.

Correct Answer: C

Rationale: The correct answer is C) Once I start feeling better, I'm looking forward to cutting down on this medication. This statement suggests that Margaret needs further instruction because it indicates a potential misunderstanding about the nature of amitriptyline treatment for depression. A) "I know I might not start feeling better for a few weeks, but I'll keep taking the medication just as the doctor prescribed" is a correct statement. It shows an understanding of the delayed onset of action of antidepressants and the importance of adherence to the prescribed regimen. B) "I'll keep some hard candies in my purse in case my mouth gets dry from the medicine" is also a correct statement. It demonstrates awareness of a common side effect of amitriptyline, which is dry mouth, and a proactive approach to managing it. D) "I'm worried I may gain some weight, but that's a small price to pay for feeling better" is not an ideal statement but does not indicate a need for immediate further instruction. Weight gain can be a side effect of amitriptyline, and the willingness to accept it for improved mental health is reasonable. In an educational context, it is crucial to emphasize to patients starting on psychotropic medications like amitriptyline the importance of following the prescribed regimen consistently, managing potential side effects, and understanding that antidepressants are typically tapered off gradually under medical supervision to prevent relapse. Patients should be encouraged to communicate openly with their healthcare providers about any concerns or misconceptions they may have about their medication.