Chief Complaint: “I don’t know how much longer I can go on like this. I’ve been down in the dumps for years and it isn’t getting any better.” History of Present Illness: 75-year-old white male present to clinic with above complaint. Lost his first, the “love of his life” wife 19 years ago. Remarried 2 years after her death and states he probably married again too soon reporting his current wife is difficult. He describes an instance, when he was at work, the second wife would not let his son, daughter-in-law and new grandbaby into his house to visit until he got home from work. The second wife also insisted that he no longer visit with his deceased wife’s family telling him ‘when you married me, you divorced that whole family’. Conversations with his wife about his concerns resulted in only short-term changes in her approaches and behaviors. Now his wife insists they sell the house he has lived in for 46 years. He reports that his memory and ability to make simple decisions have been deteriorating significantly over the last several months. His wife suggested he probably has Alzheimer’s and should go see his primary care provider about his memory issues. He reports that he engages with modest exercise daily, eats well but is waking up numerous times at night and is usually “up for good” by 5am. He blames his disrupted sleep pattern on his feeling of fatigue starting around 9am. He reports all these circumstances as contributing to his increased depression and his desire to “give up the fight”. PMH: reports usual childhood illnesses inclusive of measles, mumps and chickenpox traumatic injury, likely secondary to ‘blast’ effect, sustained during the bombing of Pearl Harbor where he was stationed as a cook; he suffered a hearing loss for six months after the bombing and was diagnosed at 54 with a rare eyes disorder resulting in poor peripheral vision that is thought to be secondary to this trauma Family Hx: Father died at 67 secondary to colon cancer; mother died at 24 secondary to influenza during an epidemic (he was 2 years old at that time) No know family history of depression or other mental illness Social Hx: HS graduate, married to HS sweetheart for 27 years then widowed Current marriage of 17 years Retired after 25-year banking career Attends Catholic mass regularly Drinks 1-2 beers several times a week, denies episode of intoxication; never smoked or used illicit drugs Drinks hot tea, reporting coffee causes too much GI distress Never driven a motor vehicle secondary to poor peripheral vision ROS: Denies HA, body aches, dizziness, fainting spells, tinnitus, ear pain, ear discharge, nasal congestion, diarrhea, constipation, change in appetite skin abnormalities, or genitourinary symptoms Denies periods of extreme irritability or elation associated with periods of sadness; denies feeling more depressed during the winter months than other seasons Reports fatigued most of the time, often feels stiffness in his neck and should.

1. Chief Complaint:
“I don’t know how much longer I can go on like this. I’ve been
down in the dumps for years and it isn’t getting any better.”
History of Present Illness:
75-year-old white male present to clinic with above complaint.
Lost his first, the “love of his life” wife 19 years ago.
Remarried 2 years after her death and states he probably
married again too soon reporting his current wife is difficult.
He describes an instance, when he was at work, the second wife
would not let his son, daughter-in-law and new grandbaby into
his house to visit until he got home from work. The second
wife also insisted that he no longer visit with his deceased
wife’s family telling him ‘when you married me, you divorced
that whole family’. Conversations with his wife about his
concerns resulted in only short-term changes in her approaches
and behaviors. Now his wife insists they sell the house he has
lived in for 46 years. He reports that his memory and ability to
make simple decisions have been deteriorating significantly
over the last several months. His wife suggested he probably
has Alzheimer’s and should go see his primary care provider
about his memory issues. He reports that he engages with
modest exercise daily, eats well but is waking up numerous
times at night and is usually “up for good” by 5am. He blames
his disrupted sleep pattern on his feeling of fatigue starting
around 9am. He reports all these circumstances as contributing
to his increased depression and his desire to “give up the fight”.
PMH:
reports usual childhood illnesses inclusive of measles, mumps
and chickenpox
traumatic injury, likely secondary to ‘blast’ effect, sustained
during the bombing of Pearl Harbor where he was stationed as a

2. cook; he suffered a hearing loss for six months after the
bombing and was diagnosed at 54 with a rare eyes disorder
resulting in poor peripheral vision that is thought to be
secondary to this trauma
Family Hx:
Father died at 67 secondary to colon cancer; mother died at 24
secondary to influenza during an epidemic (he was 2 years old
at that time)
No know family history of depression or other mental illness
Social Hx:
HS graduate, married to HS sweetheart for 27 years then
widowed
Current marriage of 17 years
Retired after 25-year banking career
Attends Catholic mass regularly
Drinks 1-2 beers several times a week, denies episode of
intoxication; never smoked or used illicit drugs
Drinks hot tea, reporting coffee causes too much GI distress
Never driven a motor vehicle secondary to poor peripheral
vision
ROS:
Denies HA, body aches, dizziness, fainting spells, tinnitus, ear
pain, ear discharge, nasal congestion, diarrhea, constipation,
change in appetite skin abnormalities, or genitourinary
symptoms
Denies periods of extreme irritability or elation associated with
periods of sadness; denies feeling more depressed during the
winter months than other seasons
Reports fatigued most of the time, often feels stiffness in his
neck and shoulders
Denies homicidal ideations, hallucinations, paranoia or
delusions
Reports suicidal thoughts, has a 22-caliber rifle at home and has
considered using to end his life
SIGECAPS:
Reports - poor sleep maintenance, loss of pleasure, he feels as

3. though he remarried too soon, he is experiencing fatigue, he is
experiencing memory disturbances, eating well, no problems
maintaining exercise regimen, is having suicidal ideations
Medications:
No routine medications
Allergies:
None
Physical Examination:
Constitutional – BP 118/73, P 83, RR 16, T 98.8, Ht 71 in, Wt
174 lbs, BMI 24
Integument – skin, hair and nails unremarkable
HEENT – PERRLA, EOMs intact, nares patent without
discharge noted, TMs gray and shiny bilateral, numerous silver
amalgams noted
Neck – supple without adenopathy, no thyromegaly
Lungs – CTA
Heart – RRR without murmur/gallop
Abdomen – soft, non-distended, active bowel sounds, non-
tender, no organomegaly
Genitalia/Rectum – deferred
Musculoskeletal – no gross abnormalities or major limitations
of ROM noted
Neurologic – CNs II-XII intact, finger-to-nose test negative,
DTRs 2+ and equal bilateral, sensory capacity intact upper and
lower extremities intact bilateral
Mental status – PHQ 9 score is 19
Diagnostics – Na 138 meq/L, K 4.2 meq/L, Cl 102 meq/L,
HCO3 27 meq/L, Bun 11 mg/dL, Cr 0.9 mg/dL, fasting Glu 106
mg/dL, Ca 9.5 mg/dL, Mg 1.8 mg/dL, AST 34 IU/L, ALT 42
IU/L, GGT 38 IU/L, Alb 4.4 g/dL,
TSH 2.8, Vit B12 98 pg/mL, Folic acid 333 ng/mL, PSA 4.9
ng/mL, Hgb 14.3 g/dL, HCT 41.4 %
Urine dipstick – 5.8 pH, SG 1.016, all other parameters negative
Assessment:

4. 1. F32.1 Major depressive disorder, single episode, moderate
2. R45.851 Suicidal ideations/thoughts
3. R73.03 Prediabetes
4. E53.9 Vitamin B deficiency
Plan:
1. Major depressive disorder
a. Diagnostic – none
b. Therapeutic – citalopram 20mg take 1 by mouth daily
dispense #30 with 2 refills
c.
Educational – effects of citalopram may not be fully
evident for up to 3 or 4 weeks; if you note fatigue exacerbated
from the citalopram take it at bedtime; RTC in 1 month for
follow up
d. Consultation/Collaboration – none
2. Suicidal ideations/thoughts
a. Diagnostic – none
b. Therapeutic – same as diagnosis #1
c. Educational – same as diagnosis #1; educate on the potential
negative impact of his current intake of beer – educate on how
to safely reduce this consumption and to avoid abrupt cessation;
educate on need to remove the 22-caliber rifle from his home;
provide information on suicide hot lines
d. Consultation/Collaboration – referral for counseling
3. Prediabetes
a. Diagnostic – none
b. Therapeutic – none
c. Educational – nutrition education aimed at making dietary
lifestyle choices of low glycemic index foods (<55 GI) that aid
in development and maintenance of stable insulin and glucose
levels
d. Consultation/Collaboration – none
4. Vitamin B deficiency
a. Diagnostic – none
b. Therapeutic – hydroxocobalamin 1000 mcg IM during this

5. OV; start on 2mg oral B-12 daily; recheck Vitamin B-12 level
in 2 to 3 months
c. Educational – nutrition education on foods high in B-12
d. Consultation/Collaboration – none