Thank you very much in advance. Hoping for your favorable response.
A. 9/10/98 John Doe
S. 34 year old white male C/O chronic fatigue. Angry. Hx of alcohol abuse. No medications. NKDA. PMHX with appendectomy 1994, two concussions at age 9 (horse related injuries). Broke right hand smashing it through a wall when first wife left (with the children), required surgical repair. Family Hx with early CAD, ETOH, “nervous breakdown.” Social Hx: smokes 2ppd, divorced twice. No longer drinking, but uses marijuana daily. Two DUI convictions. ROS: fatigue, memory loss, anger, sleep problems, heartburn, chest pain, joint pains, numbness and tingling, unsteadiness, muscle spasm – particularly in legs, chronic headaches, grinding teeth, constipation. Chronic psych Sx: moody, anger problems, empty/bored, paranoid under stress. Feels he was physically abused by alcoholic father – he used to hide when his father returned home drunk. Prozac 20mg daily didn’t help him a few years ago. Has tried Wellbutrin, Zoloft, Luvox, Tofranil, Paxil, Serzone – no positive effects, only side effects. A friend advised he come to see me.
O. Looks well. Overweight (245 lbs). HENT neg. Neck supple without adenopathy. Lungs clear. Cor without murmurs, gallops or rubs. Abd soft, non-tender, without masses or hepatosplenomegaly. Zung index very high at 84 (normal <50). Dysphoria (anxiety, rage, depression and despair) is chronic. Chronically experiencing deja vu, unreality. Seems to “check in and out a lot.” Feels like he’s “never there.” Fits 8/9 BPD criteria (anxiety, rage, depression and despair) and frequent dissociation and likely complex partial seizures
4) positive ROS
5) Hx alcohol problems
P. 1) Prozac 20mg daily x 4 days, then 40mg daily
2) on day 7 of Prozac take Tegretol 200mg x 1 dose
3) labs: CBC, chem, UA, T7, TSH, B12
4) rto 8 days
9/18/98 John Doe
cc: medication follow up
S. Dramatically better. Had no change at all from Prozac. Tegretol’s effect was dramatic. Dysphoria (anxiety, rage, depression and despair), deja vu, unreality and spaciness went away 3 hours later. Starting to recur. “I didn’t think I’d ever feel good again.” Moodiness, emptiness, boredom gone for a day as well.
O. Looks great. Smiling and happy. The change is dramatic. Haldol 1mg in office had no effect. Labs: CBC, chem, UA, T7, TSH normal. B12 very low normal at 210.
A. 1) BPD with chronic dysphoria (anxiety, rage, depression and despair) and dissociation dramatically better on Prozac/Tegretol combination
2) fatigue multifactorial – B12 deficiency a part
3) B12 deficiency
P. 1) continue Prozac at 20mg daily
2) will Rx with Tegretol 200mg in early evening only for now to stop nighttime dysphoria (anxiety, rage, depression and despair) and hopefully avoid morning grogginess that could interfere with work
3) Haldol 1mg prn – given instruction sheet
4) referred for psychological counseling
5) personalized affirmations
6) read “Happiness is a Choice” by Barry Neil Kaufman, “Embraced By the Light” by Betty Eadie, “Your Erroneous Zones” by Wayne Dyer, “Looking Out for Number One” by Robert Ringer, and “How to Win Friends and Influence People” by Dale Carnegie
7) get Zig Ziglar’s tape series and listen daily
B12 1000ug Daily
9) RTO 1 wk, needs CBC due to Tegretol
Permission by Leland M. Heller, M.D.
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