Reference no: EM133241965

Colleen is a 58 yr. old Caucasian female who presents in the office today as a referral for "anxiety and depression" from her PCP. She is a patient with the PCP who has seen her for 20 years; her medical records were sent in advance of this visit. The PCP saw her a month ago and gave her a prescription for bupropion SR 200 mg daily, and diazepam 5 mg TID PRN anxiety. Colleen is also prescribed Welchol one packet daily; lisinopril 20 mg daily; and omeprazole 20 mg daily. She also takes a daily multivitamin. She has 3 living children. She is post-menopausal, no medical hospitalizations, or surgeries. Colleen completed one year of college and used to work as a realtor but gave that up 2 years ago due to lack of business.

Colleen is here with her spouse of 39 years, Bill, and her 29 yr. old daughter Samantha. Colleen is dressed in a colorful wrinkly blouse and wearing glasses. She has on no make-up and no jewelry. Her family members are well groomed. As you greet them and tell them about your credentials, they all give you a firm handshake, make eye-contact, and ask you to call them by their first names. When taking their seats, you notice Colleen and Bill are holding hands. When you ask them what brings them here today Bill is quick to answer, "Something is happening with Colleen she doesn't want to go to church anymore, or see our friends, and some other things..." Before Bill can finish Samantha interrupts, "Mom's personality has changed over the last few years and is also doing things that seem dangerous, like driving fast, running out of gas. And lately and their pantry is empty, I mean except for all the cans of beans, there are so many cans of beans, anyway, dad has to keep ordering takeout, I think she is forgetting to do regular things". Collen says, " I am just getting older, sometimes I forget things, but that is just life I guess, my family is more worried than I am, so they wanted me to see you. I mean it is not like am seeing things or hearing things, so I am not crazy" You notice Bill squeezes her hand and Samantha places a hand on her mother's shoulder hand. You assure everyone that she is here to have an assessment and that you will share your findings as well as any resources and education you think may help them. Colleen flatly says, "I don't know about that, my mother had memory problems before her stroke and then we lost her." You say, "okay we will get to your family history but let me look over the chart from your PCP." Colleen picks up the pencil on your desk & taps her cheek. She is somewhat slumped in her chair, her movements are smooth, no tremor is noted. You ask her for the pencil back and place it back in the same spot on your desk. A few moments pass, and she picks it up again and taps her cheek and you once again ask for it back and return it to the desk, this cycle with the pencil happens periodically throughout the interview.

You note in her chart that the PCP did a physical exam, which was unremarkable, and also did a mini-cog test at that visit, you review those results and score it, then record the score in your notes:

Colleen B. Aged: 58 "draw ten until 11 am" results

You ask Colleen about the note from the PCP describing the reason for the visit. As Colleen talks you notice her vocalizations are of a normal volume, rate, and rhythm but are often accompanied by sighing. Colleen says, "Oh my doctor is just a worrywart". You say, "your PCP thinks you may be depressed and anxious, what do you think?". "Maybe," Colleen responds, "but doesn't everyone feel a little shitty nowadays?" Her family is visibly uncomfortable by her lewd vocalization. You ask, "do you feel any differently since your PCP prescribed the medicine for depression and anxiety?" The family reports that she took valium twice but became unsteady, so she hasn't tried it again. As you ask her about the symptoms of depression, her family notes she doesn't like to do the things she used to and seems mostly indifferent to the goings on around her. Bill says, "this is has gotten worse over the last year, and hasn't changed since the appointment with the PCP, and they started that new medicine, but she is grumpier". You note in her chart that her weight is about the same as it has been. The family says that there have been changes in her appetite "no not her appetite, maybe in what she eats" Bill says, "she is always chewing on something, celery, carrots, gum". Colleen looks unengaged in the conversation. Bill says she is sleeping about 8 hours a night and sleeps all the way through the night, no napping during the day. You reengage Collen and ask her about her memory and if she has any trouble thinking, she denies having trouble thinking but her daughter speaks up "no, there is something going on with her memory, mom was always very organized, but now she puts post-it notes everywhere to remind her to keep up with what she is supposed to be doing". Samantha states the post-it notes started about a year ago & "it does seem like there are more & more notes around the house..." Bill says "honey, you do a great job around the house but sometimes in the evenings you forget things like- you did the laundry and I have had to stop you from doing it all over again with the folded clothes in the basket". Collen responds "oh it is nothing, just a few regular things that people normally miss or forget. I mean I keep up with the news, I take care of you, I do so much." Colleen continues, "maybe you should get a new wife, a younger model, get one with huge boobs!" Colleen states emotionlessly. Samantha looks astonished - "MOM!" "She never used to talk like that, but she has the mouth of a sailor" Bill looks embarrassed and states, "it is true honey, you never used to curse, or anything like that." He continues "also it seems like we fight more than we used to, you get very grumpy at the smallest things." Colleen retorts "this isn't something we should talk about in front of that one (she gestures at you)." You assure her everything is confidential and ask Colleen and her family more about when they noticed changes in her organization and more about the post-its. The family notes that it began about a year ago, including she started using a pill reminder case to take her meds, she started using a calendar to stay on top of the bills, and she started using the GPS to get around everywhere. Samantha notes they live in the same small town that Colleen grew up in & surprised her to see her mother using the GPS. Collen says, "I like her voice when she tells me where to go". She seems unaware of the double entendre, even when the family snickers a bit.

You turn to Bill and ask, "you said she is cursing and other changes where she doesn't seem like herself, when did that start?" Bill says about 4 years ago. Samantha looks surprised, "I didn't know it was that long ago dad". Samantha notes that her mother has changes in other ways too, "she used to volunteer at the animal shelter, but she stopped. She said she really didn't care about the animals anymore & maybe it would be better if they were euthanized, to 'put them out of their misery'". Samantha continues, "It was so out of character for her." Colleen says, "my mother stopped caring about everyone & everything before her stroke and [expletive] one day she proposed to the pastor, I mean she tried to [expletive] him". You ask Colleen what should happen if someone forces themselves on another person and she shrugs. She denies any childhood trauma, "I mean my dad hit us, but I am sure we deserved it, it is not like I think about it now, my sister says there is more to that story, but I don't remember that, maybe that is my memory problem?" You ask Colleen about anxiety & she says she worries about her husband sometimes, "he works very hard & he is a good man, but he has to travel every day to work with the bad drivers here" and she worries about her kids sometimes, "but they are grown and can take care of themselves, it is not like worrying does anything."

What pharmacological intervention(s) will you order or change for Colleen, if any?

What are the diagnosis and differentials.

What is the working diagnosis. explain.