Chief Complaint: Mr. Bert Colton is an 89-year-old Caucasian male who presents to the clinic with his granddaughter, complaining of “I’m so panicked, I feel like I can’t calm down and I feel like I want to cry.”
History of Present Illness:
Onset: Patient described feeling restless, on edge, fatigued, and irritable since his diagnosis of open-heart surgery one year ago.
Location: Mostly when at home.
Duration: Over the past year, he has started to excessively worry more and more about multiple issues.
Characteristics: He endorsed worrying and being anxious almost all day and almost every day of the week, about what will happen to his daughter when he dies. He also worries whether she will die a terrible death if his disease is passed to his daughter or whether she might get breast cancer that his wife died from.
He worries if the day will come when his daughter cannot walk or no longer care for herself. What will her church family do without her if she can’t attend biweekly? Or what will the places where she volunteers do if she dies?
For the last six months—in addition to feeling restless, on edge, fatigued, and irritable —he has also had difficulty concentrating and cannot “turn his mind off sometimes” at night to fall asleep.
He has started having trouble walking to the store (which is one block away) for his groceries, paying his bills, going to social gatherings, and going to his neighborhood group meetings. Recently he has decreased his church attendance and volunteer experiences at the local hospital because of his symptoms.
Aggravating: Thinking about dying and leaving his family, all the work that needs done to my home, thinking about and missing my wife.
Relieving: Spending time with family.
Temporal: Worse in late evenings and sometimes in middle of the night.
Severity: “I can’t stand this feeling every day, like I need to jump out of my skin.”