Question

Case 2 Counseling Note This is a 68-year-old female who is being seen today because she feels “tired and very depressed.” She states that she has lost her appetite for the past month and has not been able to sleep well. Her medical doctor requested she see a counselor so that we can do some counseling, see if we can get her back on track, and make life more pleasurable for her again. At this time, she denies any substance abuse. She denies any suicidal thoughts or tendencies. She is oriented to time, person, and surroundings with no confusion. She cannot, at this time, identify any situation that might have triggered this state, but she does state that her youngest child just moved out of the area. When asked if this might be the trigger, she did affirm that the timing would be right and it was possible. She has agreed to meet with me twice a week to talk and see if we can get her back on track. ICD-10-PCS Code Assignment

Answer 1

Since the patient is of 68years old, and there is no known history of any psychiatric disorders, based on all the symptoms presented by the patient, it can be considered under ICD 10 F32. 09 Mild Depressive Episode without somatic syndrome.

Diagnostic guidelines : ICD 10 F32.00

Depressed mood, loss of interest and enjoyment and increased fatigability are usually regarded as the most typical symptoms of depression along with any two of the below:

1. Reduced concentration and attention

2. Reduced self esteem and self confidence

3. Ideas of guilt and unworthiness ( even in mild type)

4. Bleak and pessimistic views of the future

5. Ideas or acts of self harm or suicide

6. Disturbed sleep

7. Disturbed appetite

In this case, the criteria for mild depressive episode are fulfilled and there are few or none of the somatic symptoms present.

The patient has only few somatic symptoms like Disturbed appetite, fatigue was and disturbed sleep.