Patient Information
Name: Mr. James Carter Age: 78 Gender: Male Ethnicity: African American Marital Status: Widowed Living Situation: Lives alone in a one-story home Insurance: Medicare
Chief Complaint
“I don’t feel like myself anymore… I just feel tired and alone.”
History of Present Illness (HPI)
Mr. Carter is a 78-year-old widowed male presenting for evaluation of worsening sadness, fatigue, and social withdrawal over the past 6 months. His wife of 45 years passed away 8 months ago. Since her death, he reports decreased interest in activities he once enjoyed, including attending church and playing cards with friends. He describes poor appetite, difficulty sleeping, and low energy. He denies active suicidal ideation but expresses passive thoughts such as “Sometimes I wonder what the point is.” He reports increasing forgetfulness, including misplacing items and missing bill payments. His daughter is concerned about his ability to live independently.
Past Medical History
Hypertension Type 2 Diabetes Mellitus Osteoarthritis Hyperlipidemia
Medications
Lisinopril 10 mg daily Metformin 500 mg twice daily Atorvastatin 20 mg daily Acetaminophen as needed
Psychiatric History
No prior psychiatric diagnoses No hospitalizations No psychotropic medication history
Social History
Retired factory worker Former smoker (quit 20 years ago) No alcohol or drug use Limited social support Decreased church attendance
Functional Assessment
Independent with ADLs Difficulty with IADLs (finances, medication management) Decreased mobility due to joint pain
Mental Status Examination (MSE)
Appearance: Well-groomed, fatigued Behavior: Cooperative Speech: Slow Mood: Sad Affect: Constricted Thought Process: Logical but slowed Thought Content: No delusions/hallucinations Cognition: Mild impairment Insight/Judgment: Fair
Screening Results
PHQ-9: 15 (Moderate depression) MMSE: 25/30 (Mild cognitive impairment)
Diagnoses (DSM-5-TR)
Major Depressive Disorder, Moderate (F33.1) Mild Neurocognitive Disorder (F06.7)
Psychosocial Stressors
Bereavement Social isolation Chronic illness Limited support Financial difficulty
Treatment Plan
Start Sertraline 25 mg daily Refer to CBT and grief counseling Encourage social engagement Consider home health support Provide safety planning
Follow-Up Plan
Follow-up in 2–4 weeks Monitor mood and cognition Adjust treatment as needed