Patient’s name: P. O. P.
Age: 88 years old
Diagnoses: Major depressive disorder, recurrent moderate F33.1 and Anxiety disorder, unspecified, F41.9
88 y/o Female, Hispanic or Latino. Chief complaint: “I am feeling sad, I am missing my family in Cuba”. Patient has been struggling with anxiety exacerbated with the COVID pandemic. She came to the US in 2013, has 2 sons in CUba and lives with her daughter here in Miami. Sadness, lack of motivation, Fair energy levels. Diminish interest and pleasure. Mild cognitive impairment in progress, short term memory loss. Independent in ADLs but needs supervision. Appetite is fair, hard of hearing and legally blind from right eye. Patient feels anxious, tense and fearful. Muscle tension described.. Apprehensive expectations and unsustainable fear. No delusions or hallucinations or other psychotic process. No suicidal thoughts or ideation. Patient has decreased coping skills.
Patient has never received inpatient or outpatient psychiatric treatment. Patient does not have any family psychiatric history. Patient has good family support
Current medical diagnoses (commorbidities) Hypertension and glaucoma
Medications taking: Losartan, amlodipine, carvedilol, atorvastatin, and alphagan eye drops.
Follow up with psychiatric in 3 months for medication management or as needed
Medication ordered: Escitalopram oxalate 5mg (take one tablet by mouth once a day)
Therapy provided: Brief Psychotherapy