Major Depression With Psychotic Feature Discussion

Major Depression With Psychotic Feature Discussion

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Patient J.W.

Age 46 years old

Chief Complaint: ” I feel overwhelmed by simple tasks and have trouble staying focused” HPI: 46y/o female evaluated for feeling overwhelmed by simple tasks and being easily distracted. Pt. reports worsening energy levels, feelings of tiredness, difficulties staying on task, and the inability to stay focused with worsening symptoms that began about 1 year ago. Pt reports that she has a PCP that has found nothing physically wrong with her which she reports as “concerning.” She currently takes Trintellix 15mg daily and she is medication compliant. Pt reports her mood as “frustrated.” Major Depression With Psychotic Feature Discussion

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Pt reports no inpatient hospitalizations but has been previously prescribed the following medications: Zoloft, Prozac, Effexor, and Lexapro over the last 20 years with her best results being from Effexor. She reports having to discontinue the use of Effexor due to her being of childbearing age when prescribed but otherwise had no complications. She denies the use of alcohol or illicit drugs but smokes 3-4 cigarettes per day. She reports having a loving relationship with her husband and that he is kind and patient with her, together they are raising their 14-year-old son while taking care of their farm. She currently denies SI, HI, AH, VH, or feelings of paranoia.

Diagnosis:

Major Depressive Disorder without Psychotic Features (F33.3) & Generalized Anxiety Disorder (F41.1) Major Depression With Psychotic Feature Discussion

Differential Diagnosis:

Bipolar D/O
ADHD
Panic D/O
Labs:
LFT
Vitamin D level
CBC
TSH Level
UDS
Treatment:
Effexor 75mg BID

Titrate up as tolerated

Educate on possible side effects of Effexor

Refer to a counselor for psychotherapy to assist in managing and coping with stressors.

Return for a follow-up appointment in 4 weeks or sooner to make adjustments if needed.

Reference:

Stahl, S. M., Grady, M. M., & Muntner, N. (2021). Stahl’s essential psychopharmacology: Prescriber’s Guide. Cambridge University Press. Major Depression With Psychotic Feature Discussion