Case Study Scenario:
Mr. Robert, a 71-year-old man treated with sertraline 150 mg daily for major depressive disorder for the previous 2 years, was brought to the emergency department by his wife for a 2-day history of becoming suddenly confused, disoriented, and agitated. He could not sleep and attempted to leave the house in the middle of the night, stating that he was in a different place than at home. He became physically aggressive with his wife when prevented from leaving the house. Upon evaluation, his wife reported that he displayed erratic behavior for the previous year, making embarrassing comments in public and downloading pornography onto his computer. He believed that items he had misplaced were stolen by family members and friends and had alienated them because of this.
His wife reported that over the previous 6 months, Mr. Robert had progressively lost interest in his family and mostly watched television without speaking when at home. He was driven to eat when seeing food commercials. He developed a strong desire for potato chips and gained 14 lb. His manners deteriorated; he ate food on his plate in a specific order and stuffed his mouth, often choking at the dinner table. All his instrumental activities of daily living, along with bathing, a basic activity of daily living, were impaired.
One year earlier, Mr. Robert had scored 28 out of 30 points on the MoCA, losing points on attention and executive function tasks. His family history revealed that his father was initially diagnosed with depression, had prominent symptoms of bizarre behaviors and confabulation, and died at age 69 after 5 years of illness, including several admissions to psychiatric hospitals and later to a nursing home. A paternal cousin had died from amyotrophic lateral sclerosis.
Mr. Robert’s social history indicated that he was married once and was the father of one biological and two adopted children. He had a college degree. He was still employed as a teacher at the school where he had worked continuously for two decades, but he had significantly struggled at his job for over a year to the extent that the principal had suggested he seek medical care or take a leave of absence. He had no encounters with the law and had no substance abuse history. He was generally healthy and took no additional medications until 2 weeks previously, when his primary care physician started him on a cholinesterase inhibitor, donepezil 5 mg po qAM, but his wife had not noted any improvement. A brain MRI report from 1 year prior was read as “age-related atrophy and perivascular patchiness,” but no notable changes otherwise.
You were the in-house psychiatric consultant and asked to see this patient urgently because he was becoming increasingly agitated during his evaluation in the emergency department.
Use the SOAP note template to complete the documentation with the information provided.
· Formulate appropriate diagnoses and design a treatment plan.
· Explain what further information you will explore to aid in accurate diagnosis.
· What are your recommendations for managing Mr. Robert’s agitation?
· Discuss measures to incorporate compassionate patient-centered care.
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