Clinical note section (EDCOURSE): 1.  Serotonin syndrome.  After reevaluation of the patient including evaluation of the lab abnormalities it was felt that she likely had serotonin syndrome with obvious restlessness, increased bowel activity, agitation, and elevated white count and CPK.  She did not have fever, tremor or hyperreflexia.  Her CPK improved with IV fluids.  She dramatically improved with this discontinuation of her Prozac.  Her white count came back down towards normal.  At time of discharge, she was really feeling back to normal. 2.  Depression and anxiety with history of panic attacks exacerbated by her husband leaving her 2 weeks ago.  We discussed this.  Also, discussed the situation with a psychiatrist who is available on Friday and I discussed the situation with the patient.  In regards to her medications, we are discontinuing the Prozac and she is being reevaluated by Dr. X on Monday or Tuesday.  Cymbalta has been recommended as a good alternative medication for her.  The patient does have a counselor.  It is going to be difficult for her to go home alone.  I discussed the resources with her.  She has a daughter who will be coming to town in a couple of weeks, but she does have a friend that she can call and stay the next few days with. 3.  Hypertension.  She will continue on her usual medications. 4.  Diabetes mellitus.  She will continue on her usual medications. 5.  Diarrhea resolved.  Her electrolyte abnormalities resolved.  She had received fluid rehydration.

Dialogue:
Patient: I just had few questions. Can you tell me about my diagnosis?
Doctor: Sure. It's called Serotonin syndrome, ma'am. After careful evaluation of your labs, we found out that your white count and C P K was high, and those abnormalities lined up with serotonin syndrome. What are you experiencing right now?
Patient: I have been very restless and easily agitated, I have diarrhea. But no fever or shakiness.
Doctor: These can match serotonin syndrome as well. You deny any fever, tremor or hypperflexia so we will give you some IV fluids and I will check on you in an hour or so.
Patient: Okay. 
Doctor: Looks like your C P K counts improved with I V fluids and after discontinuing Prozac.
Patient: How are the counts now? Are they normal? Because I feel normal.
Doctor: Yes, your C P K and white blood cell counts have come back down. Almost normal now.
Patient: My husband left me two weeks ago. My panic attacks are increasing day by day.
Doctor: Okay, I see that you have a history of panic attacks and you do have depression and anxiety, is that correct? Last Friday, I talked to psychiatrist about your issues, and he recommended Cymbalta as an alternative to Prozac. 
Patient: Yes, I stopped taking Prozac, and I am going to see him on Monday or Tuesday. I have a counselor too.
Patient: I do think it will be difficult to go home alone but my daughter is coming to visit me in two weeks.
Doctor: Oh wow.
Patient: Yeah.
Doctor: That's nice. Do you have someone who can drop you home and help you?
Patient: Yes, I have a friend who does that, I am staying with her for next three days.
Doctor: Okay that sounds good. Just continue with your medications for high blood pressure and diabetes as well. So, we treated your imbalance issues and gave you IV fluids, you do not have any more diarrhea, right?
Patient: Yes, that's right.