Depression, Weight Loss, Dizziness
M.W. is a 64-year-old female who comes in to the clinic for a recheck of her depression.
She was started on Zoloft 50 mg q day one month ago. She has a history of hypertension
and is on Atenolol 50 mg q day and Maxide I q day.
S: M.W. comes in today stating that she feels more energetic than she did one month ago.
She feels that she has been more active in her daily living (she has been able to clean her
apartment and go shopping). Her sister who is with her agrees and states that she has
been more talkative with more expression. M.W. states that her appetite is decreased.
She denies nausea/vomiting, diarrhea, abdominal pain or constipation. She just isn’t
hungry lately and she wants to lose 25 pounds because she feels she is too fat. She states
that she never eats breakfast. She sometimes eats lunch and always eats dinner. She has
a piece of fruit at 7:00 p.m. and then doesn’t eat until the next day. M.W. also states that
she is dizzy lately. The dizziness is sometimes accompanied by lightheadedness but not
always. She is dizzy when she gets up in the morning and if she has been moving around
too quickly. She denies falling.
O: Blood pressure 131/80 sitting. Blood pressure standing 120/80 at this time. No
dizziness now. Pulse 84. RR 18 nonlabored. Ht. 5’4”. Wt. #170 lbs. Weight is down 9
lbs. from last month. Mucus membranes are pink and moist. Skin turgor intact. Active
bowel sounds X 4 quadrants without tenderness.