Grand Rounds Discussion: Complex Case Study Presentation

My Patient Case Study:

Patient is a 44-year-old African American male seen today for an initial evaluation and treatment with consent obtained. Patent stated, " I am struggling. I try to make things happen and stay on track. I am having hard time communicating with my family and my children, I feel paranoid and separated from everything. I know that this is not me, I need help to handle stress". Patient reported that he was discharge from psychiatrist hospital six-month ago. And since then, he has not seen any provider. Patient reports feelings of irritability, anger, paranoia, and inability to handle pressure. Patient currently lives alone and rents a room in a house, has a small group friend. Patient is on disability, and is distanced from his children and extended family. Patient further stated both the mother and father side have some mental illness. He hopes to regain motivation, attentiveness, and confidence so he can develop a better relationship with his family. Patient is currently on Wellbutrin 150mg by mouth daily for depression which was prescribed by his PCP. Patient reported no changes his depressive mood despite the fact he has been on this medication for six months or more. Provider increased the Wellbutrin to 300mg by mouth daily and Hydroxyzine 25mg by mouth every 8hrs as needed for Anxiety. Patient was educated to take Wellbutrin 300mg daily in the morning to help decrease his depression and increase his overall drive to accomplish his goals of confidence, motivation, and attentiveness. Patient denies suicidal or homicidal ideation. Patient was educated to monitor side/adverse effect and drug interaction of the medication which he some verbalized understanding. Patient will be referred for psychotherapy sessions for education on anger and stress management. Patient is educated on positive coping mechanisms to improve his mood. Patient verbalizes understanding.

PHQ Score is 15/27

Vital Sign Temp-98.6, Res-20, Pulse-76, B/P-138/82, Weight-188lbs

Patient will continue Wellbutrin 300mg daily to decrease depressive mood and Hydroxyzine 25m as needed for Anxiety.

Patient will be educated on medication side effects and adverse effects

Patient to follow up with psychotherapy

Patient will be educated on positive coping mechanisms to improve mood

Follow up in 2 weeks

Call 911 if experiencing suicidal or homicidal ideations.