Review the Geriatric Case Study patient scenario and analyze the data to determine the patient’s health status.
For this assignment:
Inpatient and Outpatient Psychiatric/Mental Healthcare: No previous psychiatric inpatient care. Has previous history of taking an SSRI for short time several years ago for anxiety and panic related to grief after wife’s passing. Denies any suicidal ideation or past attempts.
Past Psych Diagnosis(es): GAD, panic disorder, and bereavement.
Treatments: Endorses seeing a therapist after his wife died and meeting with a church grief group.
Current Psychotropic Medications: None.
Treatments:
Substance Use: Denies any use of nonprescription medication, denies use of tobacco or alcohol.
Trauma History: Denies any history of trauma.
Retired but worked in the corporate world for 30 years. Is used to being very active in community, and usually spends several hours per week helping out at the local hospital as a greeter and volunteer. He was unable to volunteer for the last month due to feeling "blah." Widowed three years ago, wife passed away from cancer. They shared 50 years of marriage and have two daughters, aged 30 and 32. One daughter lives with her family in a house down the street from him and visits daily. He no longer drives a vehicle but usually visits his daughter daily after a walk around the block. He no longer enjoys rose gardening in memory of his wife.
Spirituality: Notes that he is a Christian and attends church regularly when he feels able.
Family History of Psychiatric Mental Illness: Unknown
Family History of Suicide: Denied
Received these vaccine boosters:
Regularly wears seatbelt when riding as passenger.
No weapons in the home.
The patient disclosed additional medications only when his granddaughter left the room, stating, “They think I may possibly also have a slight case of Parkinson’s, so I take these.” He pulled two pill bottles from his jacket pocket:
The patient claims he started these meds four weeks ago.
Reports usual health as “pretty good.” Denies fever, chills, weight changes.
Denies chest pain, palpitations.
Reports feelings of feeling "blah" and anxious most of the day, with worsening anxiety in late evening. Anxiety symptoms of restlessness, racing thoughts, and feeling tense for the past three years, with an increase in symptoms over the past five months. Affect is full-ranging. Only feels irritable when anxiety worsens; denies feeling easily tearful. Reports difficulty getting up in the mornings when sleep has been disruptive with difficulty falling asleep. He wakes up several times a night and does not feel rested.
Reports difficulty falling asleep almost every night, and some middle-night awakening.
Loss of interest in hobbies and decreased pleasure in gardening.
No feelings of hopelessness, helplessness, or hostility; denies any feelings shame, or lack of motivation. Endorses some guilty feelings that he will need help with care if his hands get worse from shaking.
No increased energy; reports feeling fatigued most days, especially when sleep is poor.
Some difficulty concentrating when worrying, or with increased anxiety.
No increased or decreased appetite.
No delusions, hallucinations, feelings of persecution, hearing sounds that seem to be voices, or preoccupation with religion.
No self-inflicted injuries; no frequent thoughts of death, lack of desire to continue living, or suicidal tendency.
No homicidal thoughts.
No interpersonal relationship problems, family problems, legal problems. Concerned about recent diagnosis and health concerns. Concerned family will need to take care of him more and will lose independence.
| Height | 69 inches |
|---|---|
| Weight | 172 lbs. |
| T | 98.6 |
| P | 78 irregular |
| R | 18 |
| BP | 138/82 |
| BMI | calculate at each visit |
Mr. Bert Colton is an 89-year-old Caucasian male who articulates clearly but softly, ambulates slowly without difficulty, and is in no acute distress. General appearance is same as stated age, with a normal level of personal hygiene, no inappropriate clothing, no bizarre personal appearance.
Remainder of physical exam deferred during psychiatric mental health assessment.
A&O x 4, appearance, behavior, and speech appropriate. Thoughts coherent. Remote and recent memories intact.
Wrings hands when he speaks; no hypervigilance, heightened startle reflex, abnormal mannerisms, or uncommunicative/disinterested/hostile/inattentive attitude.
Gait: ambulates without difficulty.
No refusal to speak or loosening of association/word salad; not slowed, rapid, or difficult; normal rhythm of speech, speech tone, and speech volume.
Feels empty; appears moderately anxious, not dysphoric, euphoric, angry, elevated, or expansive.
Limited affect.
No language abnormalities; speech fluent; no dysphonia; no stuttering; language fluent and intact for naming; normal sentence structure.
Patient oriented x 4, no disorientation, short-term memory impairment, or reduced abstraction ability; diminished cognitive functioning only when anxiety is intense.
No deficiency on evaluation of connectedness; organized.
No thought content impairment; no suicidal ideation, homicidal ideations, paranoid ideations, poverty of thought, thought insertions, obsessions, irrational fears, delusions, or hallucinations.
No impaired insight, impaired judgment, or poor problem solving.
Cranial Nerves: CN II through XII intact.
Motor: Resting tremor left upper extremity noted, which resolves when holding pencil. Noted to have “pill rolling” in bilateral thumbs to index finger while ambulating. Unable to walk on heels/toes without stabilizer (counter).
No recent labs on file.