Ms. L is a married 41-year-old woman with recently diagnosed stage I breast cancer. She comes to her oncologist's office for a routine visit following her third cycle of preoperative doxorubicin hydrochloride (Adriamycin) and cyclophosphamide (Cytoxan). Ms. L's major complaint is fatigue. The oncologist had started Ms. L on paroxetine (Paxil), a selective serotonergic reuptake inhibitor (SSRI), at 20 mg qhs 2 months earlier because of concerns that Ms. L might be depressed, based on her complaints about depressed mood, difficulties sleeping, and other depressive symptoms.
The clinic nurse observes that for the first time, Ms. L's spouse has not accompanied her to the appointment, but instead, Ms. L's 17-year-old daughter has come with her. She questions Ms. L regarding how her family has been managing the stress of her cancer and treatment. Ms. L acknowledges that she and her husband have been experiencing tension related partly to sexual difficulties, and her children have seemed increasingly angry about her illness. The clinic nurse asks Ms. L if she has been seeing a mental health professional. Because Ms. L indicates that she has not, the clinic nurse refers her to a local psychiatric practice.
Psychiatry Consultation & Treatment Summary
Ms. L arrives for her appointment with the psychiatric nurse practitioner, who conducts a thorough review of Ms. L's history, including her breast cancer diagnosis and treatment. The nurse practitioner inquires about the symptoms prompting initiation of paroxetine, and her current symptoms.
Ms. L reports initially experiencing fatigue, depressed mood, insomnia, diminished interest in her usual activities, and difficulty concentrating, but describes these symptoms as fluctuating considerably. Now, she complains that she feels very sluggish, and she has developed sexual difficulties involving loss of desire and difficulties with arousal as well as orgasm.
Paroxetine helped improve the patient's mood slightly, as well as her interest in activity and her insomnia, but now she is sleeping too much. Ms. L denies having suicidal ideation, or feelings of guilt or worthlessness, and she also denies any major persistent changes in appetite or weight.
Of significance is that Ms. L experienced depressive symptoms 8 years ago and was treated with fluoxetine (Prozac) by her family physician for only 3 months with good results. Ms. L denies any other periods of depression or any family history of psychiatric illness.
The nurse practitioner diagnoses Ms. L as having an "adjustment disorder with depressed mood, rule out a major depressive episode." Free thyroxine and thyroid-stimulating hormone levels are ordered, along with a complete metabolic profile, to rule out possible physical causes of her complaints. The nurse practitioner reassures Ms. L that she probably does not have a major depression, and suspects that paroxetine may be at least contributing to some of her complaints.
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