Case study
54-year-old white female. Individual reports depression has increased. “I been dealing with my boyfriend being in the nursing home. I have no desire to do anything. I just feel depressed and all I do is lay around crying.” Individual reports anxiety the same. She reports Seroquel helps with sleep and denies side effects from medications. Individual rates life 4/10 with 10 being the happiest. She denies SI/HI at this time. Plan: continue Oxycarboxipine 300 mg daily, increase Seroquel dose to Seroquel 150 mg daily. Order Genesight test (increase Oxycaboxipine dosage pending review of test results). Follow up in 4 weeks
DX;
Bipolar disorder, Anxiety, Depression, Difficulty sleeping
Current Medications
Quetiapine 100 mg
Oxycarbazepine 300 mg
Fluticasone prop 50 mcg spr
Loratadine 10 mg
Levothyroxine sodium 50 mcg
Montelukast sod 10 mg
Losartan potassium 50 mg
Novolog 100 units/ml vial
Diltiazem HCL ER coated BEA
VIT D2 1.25 mg (50,000 unit)
Lisinopril (cough)
Sulfur (hives)
Vital signs
Hight 5’11
Weight 247 lbs
BMI 34
ROS
PYSICHIATRIC;
(+) Change in mood
(+) Depression
(+) Sadness interfering with function
(+) Anxiety
(-) Nervousness
(+) Sleep disturbance
(+) Hopelessness
(+) Worthlessness
(-) Delusions
(-) Hallucinations
HPI
Individual reports anxiety and depression most of her life. She reports childhood sexual trauma. Individual also reports grief from the loss of her adult son.
Past Psychiatric History:
Anxiety
Depression
Bipolar
Reproductive Hx
Age of menses 15
G3 T3 PO AO L2
PMHx
HTN
COPD- Bronchitis/Emphysema
Type II DM
Hyperlipidemia
PSHx
Tubal ligation, vulvectomy
FHx
Mother (deceased) cancer, mood disorder
SHx
Current smoker
Occasional alcohol