CC Stated, "I've got to do something about my depression."

HPI: 60-year-old male referred for medication treatment presents for psychiatric evaluation for Spravato. States he has had depression since he was a little boy. He states that he is extremely violent and does not like to be around people. Loud noises and movements bother him. He is hyperaware of his mental illnesses and how they present and make him feel. He has in the past seen and heard things he knows are not real and knows that these are due to him having these illnesses. He stated he sees shadows mostly, cats, dogs, he was convinced for a year that a man was in his house as one of these illusions. He also has heard minor phrases like someone telling him to "shut up" he denies that any of these hallucinations or delusions have ever been violent or told him to be violent to himself or others. He states he has SI now and then the last being three weeks ago, he was able to seek out treatment at the local ER. He has had multiple attempts at Suicide over the course of his life latest being in 2018 when he tried to overdose. In the past he has done some self-harm including cutting himself and trying to hang himself. He believes that the current regime of medications that he is on has been the best he has ever been. He no longer attends AA meetings he does still have a sponsor but does not talk to him regularly. He does not believe that they are as effective as they once were. He states he has been sobering from alcohol since 1988, he claims to use marijuana sometimes a few times a week to help calm him down or to sleep. He states his sleep is anywhere from 3-4 hours a night with multiple interruptions of tossing and turning and racing thoughts. Multiple members of his family are now living with him including his non biological daughter from his current marriage and her 2-year-old baby. This has caused significant amounts of turmoil in the household and has led to many fights between him and his wife. He even mentioned that this has become so bad they have attempted marriage counseling in the past with no success. He now believes that due to this destructive relationship although he loves his wife he may work on a divorce.

He states his depression is a 7 or 8 (on a scale of 1-10 with ten being the worst) he has multiple days of sadness and crying spells. He reports multiple episodes of feelings of guilt and wanting to self-isolate. He states he lacks energy to even perform some day-to-day tasks. He states he has multiple mood swings which occur very frequently and cause him to overreact to the situation. He reports that his anxiety is that of an 8 or 9 and thisis everyday causing him to ruminate on his problems and concerns. Family and finances are a huge trigger for this. He states he has multiple episodes of anger and irritability, and this is triggered when he asks someone to do something, and they ignore him. He states his appetite is poor, there are days where he doesn't eat at all and some days where he binges for food. He believes he has gained about 15lb in the last 4 months.

Past Psychiatric History:

• General Statement: Has a history of SI and attempts.
• Caregivers (if applicable): Very supportive wife and family
• Hospitalizations: placed into various locked facilities including *** These treatment facilities have never been longer than 3 weeks and stent from either having SI or actual attempts.
• Medication trials: Multiple medication trials have been attempted over the course of his life time; his current regimen of medications has been the best he's ever been on.
• Psychotherapy or Previous Psychiatric Diagnosis: PTSD, Bipolar Antisocial Disorder.

Substance Current Use and History: Current use of Marijuana a few times a week, along with Gambling. Has a history of Alcohol, Cocaine, Caffeine and Multiple IV Drug use.

Family Psychiatric/Substance Use History:

Mother- history of alcohol abuse (attempted suicide) *now deceased passed away after being sober in home of son.

Father: Died when he was young not much known

Siblings- 3 brothers, 3 sisters (1 sister attempted suicide, 2 brothers attempted suicide)

Kids- 7 biological children ages 16-43) (oldest daughter deceased 2019, suicide overdose)

Grandkids 6

Great grandkid's 3

Psychosocial History:

Marital: 3rd marriage supportive wife (She has a mental illness of Bipolar untreated)

Legal: Hx of various accounts of armed robbery in the Los Angeles area including and drug use, multiple times in jail *gang affiliation

Occupational: Construction boiler worker: now retired SSDI 4+Years

Medical History: Surgical interventions for a broken Right Thumb at age 17, Hx of Gallbladder extractions and Hernia repair in his mid 30's. Has a history of Hep C due to alcohol, treated twice, once with interferon in 2005, and then again with Maverick in 2019, has a current clear diagnosis.

• Current Medications:

Alubuterol 90 mcg/inhaler PRN 2 puffs Wheezing

Alprazolam 1mg PRN BID Anxiety

Amolodipine 5mg PO QD

Buprorion 200mg (12hr tablet) PO QD

Cariprazine (vraylor) 1.5mg PO Q HS

Cholestryramine 4 g packet Q DAY

Cyclobenzaprine 10mg PO QD

Lamotrigine 150mg BID PO QD

Metformin 500mg PO BID meals

Mirtazipine 7.5mg PO QHS

Nuedexta 20-10 BID PO QD

Omeprazole 20mg PO QD

Ondasteron 4mg PO BID

Prazosin 2mg (take 3 Q HS)

Primidone 50mg (2 tabs in morning and 2 tabs at Noon)

Quetiapine 100mg (take 1.5 tablets PO QHS)

Sildenafil 100mg PRN

• Allergies:

Codeine: Nausea and vomiting

• Reproductive Hx:

Multiple Children seven biological (with various partners), six grandchildren, and three great grandchildren

ROS:

• GENERAL: has increased lethargy, weight gain and fatigue
• HEENT: has hearing loss in both ears, he gets a high pitch ring every so often that can last from hours to days. c/o of dry mouth, has glaucoma, nearsightedness and far sightedness.
• SKIN: Negative for itching or redness
• CARDIOVASCULAR: Increased anxiety gives him a fear of dread in his chest
• RESPIRATORY: Severe asthma
• GASTROINTESTINAL: Negative for constipation and diarrhea.
• GENITOURINARY: Dysuria noted, pSA was high on recent labs
• NEUROLOGICAL:currently has a headache, has noticeable tremors
• MUSCULOSKELETAL: L knee is swollen, and feet hurt from long periods of standing.
• HEMATOLOGIC:
• LYMPHATICS:
• ENDOCRINOLOGIC:

Physical exam: Not applicable

Diagnostic results: CBC, CMP,

Assessment

Mental Status Examination: 60-year-old male presents as casually dressed in weather appropriate clothing as today was very chilly and snowing. He is noted to have some dirt under his fingernails, his hair is clean and trimmed. He has no noticeable body odor. His speech is of normal rate, rhythm and volume. He does not make much eye contact when talking, appears to be looking out into the distance. He does have a noticeable tremor in his hands, specifically his fingers, but this does not seem to affect his day-to-day activities. His mood is optimistic and the tone of this varies appropriately according to the context of the conversation.

The thought process is noted to be coherent, logical and goal oriented with no evidence of flight of ideas, loose associations, thought blocking, circumstantiality, tangentiality ore preservation. Thought content reveals no delusional thinking to include grandiosity, paranoia, ideas of reference any religiosity or somatization. There is some evidence of a disturbance in perception to include hallucinations as evidenced by his statement seeing shadowy figures of animals or people. There is also evidence of these delusions being vocal. He has multiple thoughts of SI, along with thoughts of self-harm but has no current plan or intent to hurt himself or others.

is alert and oriented x4. He does have some issues with memory recall, specifically his short-term memory. His comprehension and understanding of the context of the conversation appear to be adequate.

1. what are three Different and possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

2. In reflection to this case study discuss any legal/ethical considerations for this client of 60 years old (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).