Case of a 49-year-old female with complains of low mood
This is the case of a 49-year-old female, resident of West Bengal, and School teacher by occupation. The following history was taken through a telephone conversation. The patient was explained about confidentiality and written consent was taken to create the following case report.
This case report aims to record the patient's journey.
History of presenting illness
The patient is the youngest daughter, her father was a doctor, and her mother was a housewife. She has five elder brothers and one elder sister. She describes her behaviour as a child as one who was very silent and obedient. She had wonderful relations with her parents and siblings.
The patient was apparently symptomatic 28 years ago
28 years ago, the patient got married, the patient frequently had arguments at home, over small things – like if the food she prepared was not perfect, or if there was less salt in food. These arguments would cause her to have a low mood and cause her to overthink a lot as she would constantly worry about what people would say about her. The patient developed self-doubt – for example - she started constantly checking her food, to make sure it is cooked properly to avoid arguments. One year after the birth of her daughter, the patient had a miscarriage at five months of gestation.
In the year 2018, the patient on her way to school lost her balance and fell. The patient had a headache after the fall, for which she consulted a doctor, who said there is nothing abnormal. Since then the patient has had a fear of falling.
A few months into lockdown-(2019-2021), the patient had an aggravation of these symptoms.
Frequently the patient had a low mood that is still present but the frequency of these episodes has reduced. The patient explains that she feels lethargic throughout the day. The low mood is non-reactive to circumstances i.e always present. The sleep is not refreshing, the patient sleeps at around 12 AM and wakes up in the morning at about 3.30-3.45 AM due to constant worry. The patient does not go back to sleep after waking up.
There is no diurnal variation of mood.No loss of motivation or interest.
She often found herself crying during the period of lockdown, after which she felt exhausted. She constantly worries and gets anxious thinking about how she would react if there are arguments. The patient is constantly fatigued and expresses that she has a lack of energy. She complains of dull pain in her hands and legs – present on and off, localised, with no aggravating and relieving factors. She describes a reduced appetite since the lockdown. According to the daughter, she has had to be forced to eat food that she previously enjoyed eating. She has lost weight from 60 kg to 52 kg in the period of lockdown.
There are no effects on the patient’s concentration or memory. There is no diurnal variation of mood.No loss of motivation or interest.
These symptoms (low mood, pain, reduced appetite, disturbed sleep, crying and a state of worry) still persist but the frequency has reduced.
During lockdown, she has described her day-to-day schedule as –
Waking up in the morning between 5 am and 6 am. Followed by yoga for a variable amount of
time, followed by cooking, serving and eating breakfast. As she had lost her appetite during the lockdown, she did not consume food which led to gastric reflux, which was associated with headaches. She recalls crying intermittently throughout the day. The lunch and dinner timings were also variable.
In August 2020, the patient experienced lightheadedness, tiredness and headaches. On further evaluation, the patient had elevated blood pressure levels for which the patient was put on anti-hypertensive medication Amlodipine 2.5mg three times a day half an hour after food. The patient is currently on the same medication.
10 days ago, the patient was advised to get her thyroid levels checked which revealed an elevated TSH level . The patient is not on any medication.
One week ago, the patient developed a rash on her left leg. The rash spread to the rest of her body including her arms and trunk. The rash is itchy. In the last two days, the itch has reduced, but it is still present. Reliving factors include - the application of moisturizer.
Updated on 11/10/22
The patient complained of a pruritic rash on her back since yesterday .No aggravating or relieving factors .
Drug History -
Amlodipine 2.5 mg three times daily
Past History
The patient is not a known case of TB, HTN, Epilepsy, Asthma, or Heart Disease.
No history of surgeries or blood transfusion.
Family History
Father - Type 2 DM
Occupational History
The patient is a school teacher by occupation. Her work does not cause her much stress, she finds working - as a form of stress relief.
Personal History
Diet - Mixed
Appetite-Reduced - According to the daughter, she has had to be forced to eat food that she previously enjoyed eating.
Sleep - Disturbed- the patient sleeps at around 12 AM and wakes up in the morning at about 3.30-3.45 AM due to constant worry. The patient does not go back to sleep after waking up.
No Addictions
Bowel and bladder movements normal
The patient enjoys talking to people, doing puja and doing her work.
Exercise status - The patient goes for walks in the evening and does yoga and pranayama in the mornings and evenings
Previous reports-
Click here to access 2021 reports, Blood pressure monitoring and clinical images
Click here to access 2022 reports
Updated on 22/10/22
Clinical Images
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Rash -1 week ago
Blood Pressure Recordings
Blood pressure recording 19 April 2023
Discussion
Patient advocate :
She only takes one medicine - Amlodac 2.5 for high pressure timing - 6.am , 1.30 pm , and 9 pm
:: Thanks.
Have you ever come across this dosing schedule for Amlodipine? But it appears to be working for the patient? Is in vitro Amlodipine pharmacodynamics different from Real patient in vivo?
::I was seeing it for the first time.
Isn't it convenient to give a single OD dose?
Can we change it to 10mg OD?
:::
https://www.ncbi.nlm.nih.gov/books/NBK519508/
Sir Amlodipine has a half life of about 30-50 hours , giving it the ability to have once daily dosing .
::: First ask the patients advocate as to why it was given thrice daily. Also why do you want to change when it appears to be working well? Would 2.5 mg once daily work in the same manner of 7.5 mg in three divided doses as this patient is taking ?
:::https://pubmed.ncbi.nlm.nih.gov/23972579/
Sir , according to this study there is no significant difference when the dose is divided . Sir in terms of pharmacodynamics and pharmacokinetics there was no significant difference.Once daily would have better compliance .
Excellent learning point
Very interestingly this patient was scared of the higher dose number and preferred to take a smaller dose at any given point but was willing to repeat it. You can get all the previous BP recordings where she titrated these smaller doses herself and finally reached this particular dosing interval on her own and add it to your case report
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