What is the appropriate management for a 31-year-old female patient with a past medical history (PMH) of hydronephrosis, cholelithiasis, depression, and abnormal uterine bleeding (AUB), who is currently experiencing colicky pain and requesting a referral to general surgery, as well as a refill of Prozac (fluoxetine) and BuSpar (buspirone)?

From the Guidelines

The patient is a 31-year-old female with a complex medical history, including hydronephrosis, cholelithiasis, depression, and abnormal uterine bleeding, who requires a comprehensive approach to manage her conditions and improve her quality of life. The patient's history of hydronephrosis, cholelithiasis, depression, abnormal uterine bleeding, and ongoing colicky pain related to her gallbladder issues suggests a need for a multidisciplinary approach to manage her conditions. She reports feeling well on her current psychiatric medications (Prozac and Buspar) with improved anxiety and depression symptoms, denying any suicidal or homicidal ideation, as noted in her psychiatric history 1. She is contemplating returning to school and has a positive outlook on life. Despite dietary changes, she continues to experience colicky pain from her gallbladder condition. She was previously scheduled for cholecystectomy but couldn't proceed due to financial constraints. The patient now has insurance coverage and is requesting a new referral to general surgery as her previous attempt to reschedule was unsuccessful without a new referral.

• Her current symptoms and medical history suggest that a new referral to general surgery is necessary to address her gallbladder issues, as recommended by the 2017 WSES guidelines for the management of intra-abdominal infections 1.
• She has declined a repeat ultrasound at this time, preferring to be re-established with the surgical team first.
• She also has an upcoming gynecology appointment scheduled for June 6,2025, for her abnormal uterine bleeding, which will be evaluated according to the ACR Appropriateness Criteria for abnormal uterine bleeding 1. Previous referrals to nephrology, general surgery, and gynecology were cost-prohibitive, but she now has insurance coverage to proceed with these consultations.
• Medication refills for Prozac and Buspar are requested as they have been effective in managing her psychiatric symptoms, and it is essential to continue her treatment to maintain her mental health stability 1. The patient's request for a new referral to general surgery should be prioritized to address her gallbladder issues and prevent potential complications, such as gallbladder perforation, which can substantially decrease morbidity and mortality rates 1.

From the FDA Drug Label

The patient has a history of hydronephrosis, cholelithiasis, depression, and abnormal uterine bleeding (AUB). The patient's current medications include fluoxetine (Prozac) and buspirone (BuSpar), which she is taking for depression and anxiety. The patient reports that her anxiety and depression are much better, and she is requesting a refill of her medications. She denies any suicidal ideation or homicidal ideation and is contemplating returning to school.

• Chief Complaint: The patient is requesting a refill of her medications, fluoxetine and buspirone.
• History of Present Illness (HPI): The patient has a history of depression and anxiety, for which she is being treated with fluoxetine and buspirone. She reports that her symptoms have improved, and she is requesting a refill of her medications.
• Current Symptoms: The patient reports no current symptoms of depression or anxiety.
• Medications:
  • Fluoxetine (Prozac) 2
  • Buspirone (BuSpar) 3

From the Research

History of Present Illness

The patient is a 31-year-old female with a past medical history (PMH) of hydronephrosis, cholelithiasis, depression, and abnormal uterine bleeding (AUB). She reports feeling good with her current medication regimen, which includes Prozac and Bupropion.

Current Concerns

• The patient has an upcoming gynecology referral appointment scheduled for June 6,2025.
• She was previously scheduled for surgery to have her gallbladder removed but was unable to proceed due to funding issues.
• Despite changing her diet, she continues to experience colicky pain and would like to be referred back to the general surgery team.
• The patient declined a repeat ultrasound at this time and prefers to be re-established with general surgery instead.

Medication and Refill Requests

• The patient is requesting a refill of Prozac and Bupropion.
• She denies any suicidal ideation (SI) or homicidal ideation (HI) and is contemplating returning to school, feeling good about life.
• According to 4, antidepressants such as Prozac (fluoxetine) can cause hepatotoxicity, and monitoring of liver function tests is crucial.
• As noted in 5, antidepressants like Prozac and Bupropion may increase the risk of bleeding, and patients should be aware of this risk, especially when taking nonsteroidal anti-inflammatory drugs (NSAIDs) concurrently.

Surgical History and Referrals

• The patient has been referred to nephrology, general surgery, and gynecology, but these referrals were cost-prohibitive.
• She is now insured and would like to proceed with the referrals.
• As discussed in 6, cholecystectomy is a common general surgery procedure, and complications can include bile duct injury, strictures, and bleeding.
• The patient's history of cholelithiasis and previous attempt to have her gallbladder removed suggests that she may require surgical intervention in the future, and her care should be managed accordingly, as outlined in 7.

Mental Health and Well-being

• The patient's anxiety and depression are much better managed with her current medication regimen.
• She is contemplating returning to school and feels good about life, indicating an improvement in her mental health and well-being.
• As noted in 8, some antidepressants can affect gallbladder motility, and the patient's treatment plan should take this into consideration.