Discussion board 5

THEME OF THE WEEK: BRINGING IT TOGETHER, ASSESS, DIAGNOSE, AND TREAT

You are working in a behavioral health outpatient setting and your next patient to see complains of depression. He is a 29 year old who tells you that he has a long standing history of depression. The patient recently lost their job of many years and he has been struggling more with depression. He does not feel like he has much of a support system left now. He denies SI or HI. He had been taking over the counter St. Johns wort and prescription escitalopram, which was working well prior to recent events. Since his recent misfortunes, he has tried to increase his doses on his own, which he doesn’t feel has helped much. He does have a history of anxiety and was recently prescribed bupropion. He has noted some palpitations which he attributed to his anxiety. He has not been sleeping well, which he attributes to recent stress. He notes a mild HA over the past few days and did take a dose of sumatriptan yesterday with no improvement. He denies any injury to his head. Today he reports he has had some increased anxiety to the point he feels nauseated and his arms/hands are shaking. He did have 2 episodes of vomiting prior to arrival and multiple episodes of diarrhea. He has been experiencing sweating all day today. He feels his symptoms are getting worse.

On physical exam you find he is diaphoretic. He seems somewhat anxious/agitated. He does have some fine motor tremors and slightly dilated pupils. He has no unilateral weakness or facial asymmetry. Strength is equal but has some generalized rigidity. His reflexes on his upper extremity are normal but hyperreflexia on examination of his patellar reflexes. ECG, and head CT are unremarkable.

Vitals: Temp-38.1, Pulse-107, RR-20, BP-137/87, O2-97%