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If you have completed case R, this is a review. Completion of this case will not be counted toward your assignment.
You are a family physician in a six-physician group practice. Mr. Todd Bender, a 34 year-old white male, presents to your office with the chief complaint of fatigue and sleeplessness. You briefly review the chart before entering the examination room, noting that he was last seen in the office one year ago following a minor MVA:
PMH/ PSH: 3 grand mal seizures as a child -- none since age 12
ACL repair - age 19
appendectomy - age 26
MEDS: none prescribed
ALLERGIES: NKDA
SOCIAL HX: married 9 years with a 6 year old son, employed as a chef
in an upscale restaurant for the past three years, drinks a “few”
beers on the weekend, smokes one pack of cigarettes per day since
the age of 18, denies current or history of illicit drug use.
Upon entering the room, Mr. Bender slowly lifts his head and quietly says, "Hi Doc." You see a worried-appearing Mrs. Bender sitting beside her husband, rubbing his back. She quickly interjects before you have a chance to say anything, "Please Doctor, you have to help Todd -- he hasn't been sleeping, he's always tired...and he's been losing weight. His uncle was just diagnosed with lung cancer, and I want to make sure Todd doesn't have that -- I keep trying to get him to quit those darn cigarettes."
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Mr. Bender denies the following: change in his usual morning cough and hemoptysis (helping to lower the concern for lung cancer), palpitations and heat intolerance (helping to rule out hyperthyroidism), nausea, vomiting, diarrhea, melena or hematochezia (helping to rule out GI causes of weight loss). He is not taking any medication. He is not trying to lose weight. |
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Mr. Bender
acknowledges feeling depressed over the past 4 weeks, stating
"it just kept getting worse and worse." He has lost interest in
playing on his softball team and has missed the past 7 games. He
also says that when his son asks him to play, he is reluctant to
do so, because he doesn't want his son to see him "like this".
He feels sluggish and tired, and states it all seems "worthless
- like things will never get better." He denies the symptoms of
mania. You chart the symptoms that Mr. Bender acknowledges:
*--depressed mood |
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Past Psychiatric History- The patient describes passive thoughts
of dying, as well as sleep disturbance and feelings of
worthlessness after his appendectomy at age 26 -- these symptoms
lasted "a few months" and cleared up after his family physician
prescribed "a pill that helped me sleep." He also acknowledged
depressed mood, anhedonia and decreased energy while his wife
was pregnant with their son -- he sought no treatment for these
symptoms, which resolved over 4-5 months. He has never been
evaluated by a psychiatrist. He has never participated in
counseling or therapy. There is no history of psychiatric
hospitalizations. Mr. Bender denies a history of suicide
attempts. Family Psychiatric History - The patient's mother "used to take something for her nerves." There is no FHx of psychiatric hospitalizations or suicide attempts. |
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