see attached
Chief Complaint:
I dont know how much longer I can go on like this. Ive been down in the dumps for years and it isnt getting any better.
History of Present Illness:
75-year-old white male present to clinic with above complaint. Lost his first, the love of his life wife 19 years ago. Remarried 2 years after her death and states he probably married again too soon reporting his current wife is difficult. He describes an instance, when he was at work, the second wife would not let his son, daughter-in-law and new grandbaby into his house to visit until he got home from work. The second wife also insisted that he no longer visit with his deceased wifes family telling him when you married me, you divorced that whole family. Conversations with his wife about his concerns resulted in only short-term changes in her approaches and behaviors. Now his wife insists they sell the house he has lived in for 46 years. He reports that his memory and ability to make simple decisions have been deteriorating significantly over the last several months. His wife suggested he probably has Alzheimers and should go see his primary care provider about his memory issues. He reports that he engages with modest exercise daily, eats well but is waking up numerous times at night and is usually up for good by 5am. He blames his disrupted sleep pattern on his feeling of fatigue starting around 9am. He reports all these circumstances as contributing to his increased depression and his desire to give up the fight.
PMH:
reports usual childhood illnesses inclusive of measles, mumps and chickenpox
traumatic injury, likely secondary to blast effect, sustained during the bombing of Pearl Harbor where he was stationed as a cook; he suffered a hearing loss for six months after the bombing and was diagnosed at 54 with a rare eyes disorder resulting in poor peripheral vision that is thought to be secondary to this trauma
Family Hx:
Father died at 67 secondary to colon cancer; mother died at 24 secondary to influenza during an epidemic (he was 2 years old at that time)
No know family history of depression or other mental illness
Social Hx:
HS graduate, married to HS sweetheart for 27 years then widowed
Current marriage of 17 years
Retired after 25-year banking career
Attends Catholic mass regularly
Drinks 1-2 beers several times a week, denies episode of intoxication; never smoked or used illicit drugs
Drinks hot tea, reporting coffee causes too much GI distress
Never driven a motor vehicle secondary to poor peripheral vision
ROS:
Denies HA, body aches, dizziness, fainting spells, tinnitus, ear pain, ear discharge, nasal congestion, diarrhea, constipation, change in appetite skin abnormalities, or genitourinary symptoms
Denies periods of extreme irritability or elation associated with periods of sadness; denies feeling more depressed during the winter months than other seasons
Reports fatigued most of the time, often feels stiffness in his neck and shoulders
Denies homicidal ideations, hallucinations, paranoia or delusions
Reports suicidal thoughts, has a 22-caliber rifle at home and has considered using to end his life
SIGECAPS:
Reports – poor sleep maintenance, loss of pleasure, he feels as though he remarried too soon, he is experiencing fatigue, he is experiencing memory disturbances, eating well, no problems maintaining exercise regimen, is having suicidal ideations
Medications:
No routine medications
Allergies:
None
Physical Examination:
Constitutional BP 118/73, P 83, RR 16, T 98.8, Ht 71 in, Wt 174 lbs, BMI 24
Integument skin, hair and nails unremarkable
HEENT PERRLA, EOMs intact, nares patent without discharge noted, TMs gray and shiny bilateral, numerous silver amalgams noted
Neck supple without adenopathy, no thyromegaly
Lungs CTA
Heart RRR without murmur/gallop
Abdomen soft, non-distended, active bowel sounds, non-tender, no organomegaly
Genitalia/Rectum deferred
Musculoskeletal no gross abnormalities or major limitations of ROM noted
Neurologic CNs II-XII intact, finger-to-nose test negative, DTRs 2+ and equal bilateral, sensory capacity intact upper and lower extremities intact bilateral
Mental status PHQ 9 score is 19
Diagnostics Na 138 meq/L, K 4.2 meq/L, Cl 102 meq/L, HCO3 27 meq/L, Bun 11 mg/dL, Cr 0.9 mg/dL, fasting Glu 106 mg/dL, Ca 9.5 mg/dL, Mg 1.8 mg/dL, AST 34 IU/L, ALT 42 IU/L, GGT 38 IU/L, Alb 4.4 g/dL,
TSH 2.8, Vit B12 98 pg/mL, Folic acid 333 ng/mL, PSA 4.9 ng/mL, Hgb 14.3 g/dL, HCT 41.4 %
Urine dipstick 5.8 pH, SG 1.016, all other parameters negative
Assessment:
1. F32.1 Major depressive disorder, single episode, moderate
2. R45.851 Suicidal ideations/thoughts
3. R73.03 Prediabetes
4. E53.9 Vitamin B deficiency
Plan:
1. Major depressive disorder
a. Diagnostic none
b. Therapeutic citalopram 20mg take 1 by mouth daily dispense #30 with 2 refills
d. Consultation/Collaboration none
2. Suicidal ideations/thoughts
a. Diagnostic none
b. Therapeutic same as diagnosis #1
c. Educational same as diagnosis #1; educate on the potential negative impact of his current intake of beer educate on how to safely reduce this consumption and to avoid abrupt cessation; educate on need to remove the 22-caliber rifle from his home; provide information on suicide hot lines
d. Consultation/Collaboration referral for counseling
3. Prediabetes
a. Diagnostic none
b. Therapeutic none
c. Educational nutrition education aimed at making dietary lifestyle choices of low glycemic index foods (<55 GI) that aid in development and maintenance of stable insulin and glucose levels
d. Consultation/Collaboration none
4. Vitamin B deficiency
a. Diagnostic none
b. Therapeutic hydroxocobalamin 1000 mcg IM during this OV; start on 2mg oral B-12 daily; recheck Vitamin B-12 level in 2 to 3 months
c. Educational nutrition education on foods high in B-12
d. Consultation/Collaboration none
Use your lecture materials to determine what CPT E&M Code to utilize for this new patient encounter.
You may choose to assign the code based on the anticipated/guestimate amount of time the provider would spend with the patient in the encounter or you may choose to utilize the Medical Decision Making (MDM) approach. If you choose the MDM include the following information in your discussion:
1. the level of history taking achieved identify the history elements present
2. the type of exam performed identify the number of systems and bulleted points in the note
3. the level of medical complexity encompassed include # of points for a) diagnoses/management options, b) amount/complexity of data reviewed, and c) level of risk for complications, morbidity, mortality
Chief Complaint:
I dont know how much longer I can go on like this. Ive been down in the dumps for years and it isnt getting any better.
History of Present Illness:
75-year-old white male present to clinic with above complaint. Lost his first, the love of his life wife 19 years ago. Remarried 2 years after her death and states he probably married again too soon reporting his current wife is difficult. He describes an instance, when he was at work, the second wife would not let his son, daughter-in-law and new grandbaby into his house to visit until he got home from work. The second wife also insisted that he no longer visit with his deceased wifes family telling him when you married me, you divorced that whole family. Conversations with his wife about his concerns resulted in only short-term changes in her approaches and behaviors. Now his wife insists they sell the house he has lived in for 46 years. He reports that his memory and ability to make simple decisions have been deteriorating significantly over the last several months. His wife suggested he probably has Alzheimers and should go see his primary care provider about his memory issues. He reports that he engages with modest exercise daily, eats well but is waking up numerous times at night and is usually up for good by 5am. He blames his disrupted sleep pattern on his feeling of fatigue starting around 9am. He reports all these circumstances as contributing to his increased depression and his desire to give up the fight.
PMH:
reports usual childhood illnesses inclusive of measles, mumps and chickenpox
traumatic injury, likely secondary to blast effect, sustained during the bombing of Pearl Harbor where he was stationed as a cook; he suffered a hearing loss for six months after the bombing and was diagnosed at 54 with a rare eyes disorder resulting in poor peripheral vision that is thought to be secondary to this trauma
Family Hx:
Father died at 67 secondary to colon cancer; mother died at 24 secondary to influenza during an epidemic (he was 2 years old at that time)
No know family history of depression or other mental illness
Social Hx:
HS graduate, married to HS sweetheart for 27 years then widowed
Current marriage of 17 years
Retired after 25-year banking career
Attends Catholic mass regularly
Drinks 1-2 beers several times a week, denies episode of intoxication; never smoked or used illicit drugs
Drinks hot tea, reporting coffee causes too much GI distress
Never driven a motor vehicle secondary to poor peripheral vision
ROS:
Denies HA, body aches, dizziness, fainting spells, tinnitus, ear pain, ear discharge, nasal congestion, diarrhea, constipation, change in appetite skin abnormalities, or genitourinary symptoms
Denies periods of extreme irritability or elation associated with periods of sadness; denies feeling more depressed during the winter months than other seasons
Reports fatigued most of the time, often feels stiffness in his neck and shoulders
Denies homicidal ideations, hallucinations, paranoia or delusions
Reports suicidal thoughts, has a 22-caliber rifle at home and has considered using to end his life
SIGECAPS:
Reports – poor sleep maintenance, loss of pleasure, he feels as though he remarried too soon, he is experiencing fatigue, he is experiencing memory disturbances, eating well, no problems maintaining exercise regimen, is having suicidal ideations
Medications:
No routine medications
Allergies:
None
Physical Examination:
Constitutional BP 118/73, P 83, RR 16, T 98.8, Ht 71 in, Wt 174 lbs, BMI 24
Integument skin, hair and nails unremarkable
HEENT PERRLA, EOMs intact, nares patent without discharge noted, TMs gray and shiny bilateral, numerous silver amalgams noted
Neck supple without adenopathy, no thyromegaly
Lungs CTA
Heart RRR without murmur/gallop
Abdomen soft, non-distended, active bowel sounds, non-tender, no organomegaly
Genitalia/Rectum deferred
Musculoskeletal no gross abnormalities or major limitations of ROM noted
Neurologic CNs II-XII intact, finger-to-nose test negative, DTRs 2+ and equal bilateral, sensory capacity intact upper and lower extremities intact bilateral
Mental status PHQ 9 score is 19
Diagnostics Na 138 meq/L, K 4.2 meq/L, Cl 102 meq/L, HCO3 27 meq/L, Bun 11 mg/dL, Cr 0.9 mg/dL, fasting Glu 106 mg/dL, Ca 9.5 mg/dL, Mg 1.8 mg/dL, AST 34 IU/L, ALT 42 IU/L, GGT 38 IU/L, Alb 4.4 g/dL,
TSH 2.8, Vit B12 98 pg/mL, Folic acid 333 ng/mL, PSA 4.9 ng/mL, Hgb 14.3 g/dL, HCT 41.4 %
Urine dipstick 5.8 pH, SG 1.016, all other parameters negative
Assessment:
1. F32.1 Major depressive disorder, single episode, moderate
2. R45.851 Suicidal ideations/thoughts
3. R73.03 Prediabetes
4. E53.9 Vitamin B deficiency
Plan:
1. Major depressive disorder
a. Diagnostic none
b. Therapeutic citalopram 20mg take 1 by mouth daily dispense #30 with 2 refills
c. Educational effects of citalopram may not be fully evident for up to 3 or 4 weeks; if you note fatigue exacerbated from the citalopram take it at bedtime; RTC in 1 month for follow up
d. Consultation/Collaboration none
2. Suicidal ideations/thoughts
a. Diagnostic none
b. Therapeutic same as diagnosis #1
c. Educational same as diagnosis #1; educate on the potential negative impact of his current intake of beer educate on how to safely reduce this consumption and to avoid abrupt cessation; educate on need to remove the 22-caliber rifle from his home; provide information on suicide hot lines
d. Consultation/Collaboration referral for counseling
3. Prediabetes
a. Diagnostic none
b. Therapeutic none
c. Educational nutrition education aimed at making dietary lifestyle choices of low glycemic index foods (<55 GI) that aid in development and maintenance of stable insulin and glucose levels
d. Consultation/Collaboration none
4. Vitamin B deficiency
a. Diagnostic none
b. Therapeutic hydroxocobalamin 1000 mcg IM during this OV; start on 2mg oral B-12 daily; recheck Vitamin B-12 level in 2 to 3 months
c. Educational nutrition education on foods high in B-12
d. Consultation/Collaboration none
