Final Case Study!
Posted on: Wednesday, August 9, 2023 2:26:56 PM EDT
Module 7
Evolving Case Study
Depression
DEMOGRAPHICS
Patient Name:  Roberta Felina
Age: 68
Gender: Female
SUBJECTIVE
Past Medical History: COPD, hypertension, major depressive disorder, Hashimoto’s thyroiditis
Current Medications:
COPD- Albuterol inhaler as needed, Trelegy 100/62.5/25mcg
HTN- lisinopril 10mg daily
Depression- sertraline 50mg daily
Hypothyroidism- levothyroxine 112mcg daily
Surgical History: Hysterectomy 20 years ago, right ankle fracture repair
Allergies: Macrolides, Penicillin, Strawberries
Social History:
Smoking status: Former smoker- smoked 1 pack cigarettes for 20 years, quit 20 years ago
Alcohol:  None
Diet:  Follows low sodium diet
Exercise: Walks in neighborhood 1 hour daily
Family History: Unknown, patient is adopted
Chief Complaint:  “Worsening depression”
HPI: Mrs. Felina presents to the office today with worsening depression. She has taken 50mg of sertraline for many years and it has worked well for her. However, since her ankle fracture and surgery last year her activity has been restricted. She is unable to go on long walks out of fear of falling again. She lacks motivation, she just wants to lay in bed all day. When she does go out she finds enjoyment in activities. She has not had any self-harm thoughts. She is open to starting counseling but feels she may need to either change her medications or add a new medication. She has never taken anything for depression aside from her sertraline
ROS:
CONSTITUTIONAL: Patient denies fevers, chills, sweats and weight changes.
CARDIOVASCULAR: Denies chest pains, palpitations, orthopnea, paroxysmal nocturnal dyspnea, extremity edema
RESPIRATORY: Complains of dyspnea on exertion, wheezing, and productive cough
NEUROLOGIC: No chronic headaches, no seizures. Patient denies numbness, tingling or weakness.
PSYCHIATRIC:  Complains of worsening depression. Denies suicidal and homicidal thoughts. Has anxiety about going out and doing activity, has not had panic attacks.
OBJECTIVE
-Vitals-
Height: 5’ 3”  Weight: 135 lbs  BMI: 23.9
Temperature: 97 F    Blood pressure: 130/70 Heart rate: 74  SPO2: 98%  Pain: 0
-Physical Exam-
GENERAL: Patient appears to be in significant pain  HEART: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop
LUNGS:  Wheezing to bilateral upper airway, rhonchi scattered throughout, lungs are a little tight
EXTREMITES:  Swelling, ecchymosis to the right ankle, no obvious deformity. The patient is unable to bear weight on the right ankle. She has severe tenderness over the medial malleolus. Very limited ROM of the ankle due to pain
NEUROLOGICAL:  DP pulses and sensation to distal foot intact
Assessment:
F33. 1 Major Depressive Disorder (MDD), Recurrent, Moderate
Plan:
F33. 1 Major Depressive Disorder (MDD), Recurrent, Moderate
Student to determine