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Chief Complaint:

“I don’t know how much longer I can go on like this. I’ve been down in the dumps for years and it isn’t 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 wife’s 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 Alzheimer’s 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

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 don’t know how much longer I can go on like this. I’ve been down in the dumps for years and it isn’t 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 wife’s 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 Alzheimer’s 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