History & Physical
Identifying Data:
Full Name: AG
Address: Queens, NY
Date & Time: March 8th, 2020 1:10 PM
Location: Queens Hospital Center – CPEP
Religion: Unknown
Source of Information: Self, Reliability Good
Source of Referral: Parents
Chief Complaint: “I just can’t cope with all the pressure at school”
History of Present Illness:
16 y/o Caucasian female, high school student in 10th grade, domiciled with family (mother, father, and two younger brothers) with no reported past psych hx, with no reported PMHx, brought in by family who were concerned with her recent weight loss, decreased appetite, lack of sleep, and suicidal ideation.
Patient was seen in CPEP interviewed in private, then with mother present. Patient was cooperative, and appeared very depressed with anhedonia, anergia. Patient stated she broke up with her boyfriend about 6 weeks ago and since that time she has not slept more than 4-5 hrs a night. Also reports an unintended 15lb weight loss with decreased appetite. She states that nothing interests her and she is unable to concentrate at home or at school. She has low energy and not hanging out with friends like she was in the past. She states that when she’s with her friends “things are just not fun anymore.” She is slightly irritable and annoyed with questioning. She admits to hearing a voice that tells her that she is “no good.” States she has her the voices intermittently for last 1-2 weeks but daily for the last week. She also admits to suicidal ideation over the last few days, but denies she would act on them because it is a “sin.” She denies having a suicide plan. She denies any HI/VH, paranoia, or delusions. Pt denies taking any psychiatric medication or known psych history. She also denies any alcohol, smoking, and substance use. Her mother A.A (718-123-4567) states that patient is usually a happy, cheerful, obedient, and good student. However lately she has been depressed, barely sleeping or eating. and at first her and her husband have been giving patient space to cope with recent breakup but has been growingly concerned especially with grades dropping. Mother states that both her and husband works a lot and depends on her daughter to take care of household chores and her siblings. Mother denies knowing about patient’s suicidal ideation and AH.
Psychiatry Drug Cards
| Drug Name: | Fluphenazine (Prolixin) |
| Drug Class: | 1st Generation Antipsychotic |
| MOA: | Selectively antagonizes dopamine D2 receptors |
| Indications: | Psychosis, schizophrenia (esp. positive symptoms) |
| Contraindications: | Comatose pts, CNS depression, respiratory depression, bone marrow depression, hepatotoxicity |
| Adverse Reactions: | Neuroleptic Malignant Syndrome (NMS), Extrapyramidal Sx (EPS), Tardive dyskinesia, impotence, nausea, headache, depression |
| Monitoring: | LFTs, CBC if hx of leukopenia/neutropenia, BUN/Cr |
| Starting and Maximal dose | Comes in tab, solution, and Injection.
Start:1-2.5 mg/day PO Max: 40 mg/day D/C if ANC <1000 |
| Drug Name: | Sertraline (Zoloft) |
| Drug Class: | Selective Serotonin Reuptake inhibitor (SSRI) |
| MOA: | Selectively inhibits CNS uptake of serotonin |
| Indications: | Major Depressive disorder, OCD, panic disorder, PTSD, PMDD, social anxiety disorder |
| Contraindications: | Inc. suicide risk in children, adolescents and young adults. Disulfiram use, avoid abrupt withdrawal |
| Adverse Reactions: | Serotonin syndrome, GI upset, sexual dysfunction, HA, anxiety, insomnia, weight changes, depression exacerbation |
| Monitoring: | Sx of suicidality, unusual behavior changes, height and weight in children/adolescents |
| Starting and Maximal dose | Come in Tab and Solution. Taper dose gradually to d/c
Major depression: start at 50mg PO qd, Max: 200 mg/day PTSD: start 25 mg PO qdx1wk, then 50 mg PO qd. Max: 200 mg/day |
| Drug Name: | Aripiprazole (Abilify) |
| Drug Class: | 2nd Generation Antipsychotic |
| MOA: | Partially agonizes dopamine D2 and serotonin 5-HT1A receptors, antagonizes serotonin 5-HT2A receptors |
| Indications: | Schizophrenia, Bipolar 1 disorder, Major depressive disorder, |
| Contraindications: | Inc. suicide risk in children, caution if 3rd trimester pregnancy, elderly, CVA, cardiovascular disease, hypovolemia and such. |
| Adverse Reactions: | NMS, EPS, tardive dyskinesia, dystonia, HA, weight gain, anxiety, insomnia, diabetes, etc. |
| Monitoring: | Fasting glucose at baseline if diabetes risk, CBC, weight, sx of suicidality, or unusual behaviors |
| Starting and Maximal dose | Comes in Tab form. D/C if ANC<1000.
Schizophrenia: start 10-15 mg PO qd, Max: 30mg/day Bipolar I disorder: start 15mg PO qd, Max 30mg/day |
| Drug Name: | Lithium |
| Drug Class: | Bipolar disorder, Mood Stabilizer |
| MOA: | Alters neuronal sodium transport, increases NE & serotonin receptor sensitivity |
| Indications: | Bipolar I disorder (acute manic./mixed and maintenance TX), schizoaffective disorder, |
| Contraindications: | Brugada syndrome, CrCl<30, severe renal disease, caution in pregnancy, elderly, thyroid disorder, and such. |
| Adverse Reactions: | Lithium toxicity (>1.5mEq/L), seizures, coma, tremor, hypothyroidism, diabetes insipidus, hyperparathyroidism/hypercalcemia, arrhythmias, weight gain, |
| Monitoring: | Narrow therapeutic index à monitor plasma levels every 4-8 wks, pregnancy test, CBC, UA, Cr, TSH, Ca2+, ECG |
| Starting and Maximal dose | Comes in Capsules, Tabs, and solution
Bipolar I disorder – start 300 mg PO TID, and inc. by 300 mg/day and adjust based on tx response Schizoaffective disorder – 900-1200 mg/day PO (tid or qid) and adjust based on tx response |
| Drug Name: | Duloxetine (Cymbalta) |
| Drug Class: | Serotonin & Norepinephrine reuptake inhibitors (SNRI’s) |
| MOA: | Inhibits reuptake of serotonin and norepinephrine |
| Indications: | Major depressive disorder, GAD, diabetic neuropathic pain, fibromyalgia, chronic musculoskeletal pain |
| Contraindications: | Inc. suicide risk in children, CrCl <30, alcohol abuse, caution in MAOI use, renal/hepatic impairment. Avoid abrupt d/c. |
| Adverse Reactions: | Serotonin syndrome, Hypertension, dizziness, GI upset, sexual dysfunction, HA, anxiety, insomnia, weight changes, depression exacerbation |
| Monitoring: | Cr, BP at baseline, Sx of suicidality, unusual behavior changes, height and weight in children/adolescents |
| Starting and Maximal dose | Comes in Capsules. Taper dose gradually to D/C
Major depressive disorder – start at 20-30mg PO bid, Max:120mg/day GAD: start 30mg PO qd, Max:120mg/day |
This entry is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International license.
