In this assignment, you will review the Geriatric Interactive Case Study patient scenario and analyze the data to determine the health status of the patient.
Select the Patient Subjective Information tab. Within this tab, you will be able to watch a video to gain more insight regarding the patient as well as view important patient details.
For this assignment, you will
Your case study write up should include specific reference to relevant guidelines and other clinical information. The national guidelines should also be considered within treatment plans.
When you have completed viewing the patient information, download the Comprehensive Case Study Paper Template (Word) from the assignment page in Moodle. Use this document to complete the assignment and then submit it to the assignment drop box. Additionally, there is an Exemplar document for review to help guide your case study write up.
Substance Use: Denies any use of nonprescription medication, denies use of tobacco or ETOH.
Trauma History: Denies any past 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 go to volunteer work for the last month due to feeling down. 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 does not drive anymore, but usually visits his daughter daily after a walk around the block. He enjoys gardening and has a rose garden in memory of his wife. Denies history of tobacco, ETOH, or drug use.
Spirituality: Note that he is a Christian that attends church regularly when he feels able.
Family History of Psychiatric Mental Illness: Unknown
Family History of Suicide: Denied
No recent travel outside the US.
Regularly wears seatbelt when riding as passenger.
No weapons in the home.
The patient discloses additional medications only when his granddaughter leaves the room, stating, “They think I may possibly also have a slight case of Parkinson’s, so I take these.” He pulls two pill bottles from his jacket pocket:
The patient claims he started this four weeks ago.
Reports usual health as “pretty good.” Denies fever, chills, weight changes.
Denies chest pain, palpitations.
Denies coordination problems, numbness, tingling. Endorses some recent weakness and slight tremors in his hands. Denies seizures or frequent headaches. Not aware of memory problem.
Denies h/o head injury.
Denies feelings of depression, but reports feelings of panic and anxiousness most of the day, with worsening anxiety in late evening. Anxious for the past three years, with an increase in symptoms over the past three to six 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 poor.
Reports difficulty falling asleep almost every night, and some middle-night awakening.
No loss of interest or pleasure in activities, although reports he has started to avoid some social activities that cause him to feel anxious.
No feelings of hopelessness, helplessness, or hostility; denies any feelings shame, or lack of motivation. Endorses some feelings of guilt 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.
| Ht | 69 inches |
|---|---|
| Wt | 172 lbs. |
| T | 98.6 |
| P | 78 irregular |
| R | 18 |
| BP | 138/82 |
| BMI | calculate at every visit |
Mr. Bert Colton is an 89-y/o 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&Ox4, 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.
Slight tremor intermittently in hands; normal gait and stance.
No refusal to speak or loosening of association/word salad; not slowed, rapid, or difficult; normal rhythm of speech, speech tone, and speech volume.
Not dysthymic or depressed; appears moderately anxious, not dysphoric, euphoric, angry, elevated, or expansive.
Full ranging; not blunted or constricted.
No language abnormalities; speech fluent; no dysphonia; no stuttering; language fluent and intact for naming; normal sentence structure.
Patient oriented x4, 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 with holding pencil. Noted to have “pill rolling” in bilateral thumbs to index finger while ambulating. Gait is slightly uneven but coordinated and steady. Unable to walk on heels/toes without stabilizer (counter). Did not attempt squat and tandem walk due to OA of knee. Cerebellar: RAM intact; finger-to-nose smoothly intact but slow progression.
***No recent labs on file.