Geriatric Psychosocial Case Build a matter to
Patient Knowledge
Name: Mr. James Carter
Age: 78
Gender: Male
Ethnicity: African American
Marital Standing: Widowed
Living Field: Lives on my own in a one-memoir dwelling
Insurance protection: Medicare
Chief Criticism
“I don’t feel love myself anymore… I actual feel tired and on my own.”
History of Present Illness (HPI)
Mr. Carter is a 78-year-ragged widowed male presenting for overview of worsening sadness, fatigue, and social withdrawal at some stage in the final 6 months. His wife of Forty five years passed away 8 months ago. Since her demise, he studies lowered ardour in activities he once loved, including attending church and enjoying cards with traffic. He describes downhearted proceed for meals, scenario sleeping, and low energy.
He denies stuffed with life suicidal ideation but expresses passive thoughts equivalent to “In most cases I ponder what the level is.” He studies increasing forgetfulness, including misplacing objects and lacking bill payments. His daughter is concerned about his ability to live independently.
Previous Scientific History
Hypertension
Kind 2 Diabetes Mellitus
Osteoarthritis
Hyperlipidemia
Medicines
Lisinopril 10 mg day-to-day
Metformin 500 mg twice day-to-day
Atorvastatin 20 mg day-to-day
Acetaminophen as wished
Psychiatric History
No prior psychiatric diagnoses
No hospitalizations
No psychotropic remedy historical past
Social History
Retired manufacturing facility employee
Dilapidated smoker (quit twenty years ago)
No alcohol or drug reveal
Restricted social give a boost to
Decreased church attendance
Purposeful Overview
Unbiased with ADLs
Disaster with IADLs (budget, remedy administration)
Decreased mobility on account of joint wretchedness
Psychological Standing Examination (MSE)
Appearance: Neatly-groomed, fatigued
Behavior: Cooperative
Speech: Sluggish
Mood: Unhappy
Maintain an impact on: Constricted
Realizing Route of: Logical but slowed
Realizing Yell: No delusions/hallucinations
Cognition: Gentle impairment
Insight/Judgment: Dazzling
Screening Outcomes
PHQ-9: 15 (Life like despair)
MMSE: 25/30 (Gentle cognitive impairment)
Diagnoses (DSM-5-TR)
Most predominant Depressive Disorder, Life like (F33.1)
Gentle Neurocognitive Disorder (F06.7)
Psychosocial Stressors
Bereavement
Social isolation
Power illness
Restricted give a boost to
Monetary scenario
Medicine Realizing
Originate Sertraline 25 mg day-to-day
Focus on over with CBT and disaster counseling
Wait on social engagement
Again in mind dwelling nicely being give a boost to
Present safety planning
Prepare-Up Realizing
Prepare-up in 2–4 weeks
Display screen temper and cognition
Adjust remedy as wished
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