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Original Question
Case Study: An isolated 70-year-old Asian man, Raymond, lost his wife six months ago. Though he has long disliked people, he now finds himself suffering “unbearable” loneliness. He states he hasn’t considered suicide but has increased his alcohol consumption. He notes typically drinking “a six-pack every evening in order to stop thinking so that I can fall asleep.” Before his wife passed, he had been sober for 20 years. He states he just feels like he is withering away and that he feels like he is almost dead. Mr. Zing also remarks that, independent of his dizziness symptoms, he feels unsteady on his feet when walking. He has started using a cane but doesn’t like to use it inside. When asked about previous falls, he says he hasn’t fallen. However, he says his elderly neighbor recently fell and is now in a nursing home. Now he’s fearful about falling and becoming a burden to his family. Although Mr. Zing has spinal stenosis, a recent steroid injection has relieved severe low back pain. Now he suffers only from lower back stiffness for several hours in the morning. He denies any specific weakness in his legs. Medical Problem list: Hypertension, L3-5 spinal stenosis and chronic low back pain and leg numbness/paresthesias, Depression, Benign prostatic hypertrophy, with 3-4x/night nocturia and occasional incontinence, Hyperlipidemia, Gastroesophageal reflux disease, B12 deficiency, Allergic rhinitis, Glaucoma, Nummular eczema, Medications: Valsartan 80 mg daily, Citalopram 40 mg daily, Flomax 0.8 mg at bedtime, Finasteride 5 mg daily, Lipitor 40 mg at bedtime, Omeprazole 20 mg daily, Cyanocobalamin 1 mg daily, Claritin 10 mg daily, Flonase nasal spray two puffs to each nostril daily, Gabapentin 300 mg tabs 2 tabs three times daily, Tylenol 500 mg one to two four times daily prn, Brimonidine tartrate 0.15% ophth 1 drop OU twice daily, Cosopt 2%-0.5% 1 drop OU at hs, Latanoprost 0.005% 2 drops OU at hs, Trazodone 25 mg at hs, Calcium carbonate 500 mg 1-2 tabs three times daily. Review of Systems: Positive for fatigue, poor vision in his left eye, constipation, nocturia three to four times a night, frequent urinary incontinence, low back stiffness, difficulty concentrating, depression, dry skin, hoarseness, and nasal congestion. Vitals: Supine – 135/76, 69; Sitting – 112/75, 76; Standing – 116/76, 74 R 20, T 96.8, O2 98%, Pain 3 on 0-10 scale, BMI: 19 Physical Exam Constitutional: This is a thin, alert, older Asian male in no apparent distress, pleasant and cooperative, but with a notably flat affect. Head: Normocephalic / atraumatic. ENMT: Wearing glasses. Acuity 20/30 R, 20/70 L. CV: Regular rate and rhythm normal S1/S2 without murmurs, rubs, or gallops. Respiratory: Clear to auscultation bilaterally. GI: Normal bowel tones, soft, non-tender, non-distended. Musculoskeletal: Strength: UE strength 5/5 B biceps, triceps, deltoids; LE strength 4+/5 bilateral hip flexors and abductors; 4+/5 bilateral knee flexors/extensors; 5/5 bilateral AF/AE; 5/5 bilateral DF and PF. No knee joint laxity. Foot exam shows no calluses, ulcerations, or deformities. Neurology: Cognitive screen: recalled 3/3 items. Whisper test for hearing: Intact. Tone/abnormal movements: Tone is mildly increased in both legs; normal tone in both arms. Sensation is intact to light touch and pain throughout. Reflexes are normal and symmetric. Psych: PHQ-2 = 4/6. Questions: Accompanied by: CC: HPI: S- Crisis Issues: Reviewed Allergies: Current Medications: ROS: O- PE: (not always required and performed, especially in psychotherapy only visits) Heart- Lungs- Skin- Labs: Results of any Psychiatric Clinical Tests: MSE: A – with (ICD-10 code) Differential Diagnoses: choose 3 differential diagnoses (give rationale for diagnoses to support DSM5 criteria) 1. 2. 3. Definitive Diagnosis: P- Pharm: Non/Pharm: Psychotherapy Modality used: Interventions/Homework: Educations: Safety Plan:
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