Casestudy______.docx

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

 

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