Anton, a 70 year old male, was brought to the ER by his son due to agitation. He is a retired professor and has been living independently with his wife, who helps him manage daily tasks. Since 3 years ago, his family has noticed that he has become more forgetful. He repeats questions, occasionally misplaces items like his wallet or keys, and has trouble following conversations with multiple people. He continues to dress himself and prepare simple meals. His wife helps him remember appointments and medication times. He is able to go out to the park weekly to meet up with friends. His family has been monitoring his kidney function regularly at home through a laboratory service because of his history of chronic kidney disease stage 3. 2 months ago his creatinine level was 1.4 mg/dL. A repeat test at home done today was at 3.8 mg/dL. He has had no psychiatric consult in the past. He used to drink alcoholic beverages but has stopped ever since he was diagnosed with chronic kidney disease. His son noted that since 3 days ago, there were times when he doesn’t know the year or where he is. He would speaks in short, rambling sentences that do not make sense and not recognize his family members, but would be back to his normal self. He has restless behavior, picking at his bedsheets and trying to get out of bed repeatedly. He would claim that he needs to go to college to teach. Anton is unable to consistently follow conversations. His wife notes that he has been urinating less frequently over the past week and has seemed increasingly lethargic during the day before the confusion began. He has had no fever, head trauma, or new medications. Physical examination reveals dry mucous membranes and reduced skin turgor. Vital signs show blood pressure 100/65 mmHg and heart rate 105 beats per minute. He denies thoughts of self-harm but is unable to reliably answer questions due to confusion. He has been hospitalized once before for a kidney stone removal five years ago, with no complications. On mental status examination, he is drowsy but arousable, disoriented to time and place, and has fragmented speech. He appears to misidentify his son as a student. He claimed to have no illness. 1. Present the following information based on the case given: a. Identifying data b. Chief complaint c. Premorbid personality d. History of present illness e. Past medical and past psychiatric history f. Family history g. Personal history (anamnesis) i. Prenatal & Perinatal ii. Early Childhood (0-3) iii. Middle Childhood (3-11) iv. Late Childhood (Puberty & Adolescence) v. Adulthood vi. Occupational History vii. Marital & Relationship viii. Military History ix. Educational History x. Religion History xi. Social Activity xii. Current Living Condition xiii. Legal History xiv. Sexual History 2. If the information was not given, include what questions the interviewer should have asked. 3. What are the mental status examination findings in this patient? Include the following: a. Appearance b. Overt Behavior c. Attitude d. Speech e. Mood and Affect f. Thought i. Form ii. Content g. Perceptions h. Sensorium i. Alertness j. Orientation k. Concentration l. Memory (immediate, recent, long-term) m. Calculations n. Fund of Knowledge o. Abstract reasoning p. Insight q. Judgment 4. If the information was not given, include what questions the interviewer should have asked. 5. What are the pertinent physical examination (including neurologic examination) findings in this patient? 6. If the information was not given, include what the interviewer should have done. 7. What diagnostic, lab workups and imaging would you do and why? 8. What are your differentials? 9. What is your DSM 5 TR diagnosis? 10. What is the DSM-5-TR diagnostic criteria of this disorder? 11. What medications would you give for Ellen? 12. Will you hospitalize Ellen? If yes, will you admit her to a psychiatric ward? Why or why not?

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