Interpreting Case Study: Therapeutic Observation

Mr. Peyser is a 63-year-old male here today with his friend and caregiver, Joyce to follow up on some laboratory studies, as well as a recent hospitalization and alcohol issue.

HPI

The patient tells me two weeks ago Saturday he was feeling somewhat down. He describes himself as feeling depressed. He said he went and bought a bottle of whiskey. He had multiple drinks and then was driving to a part-time job. He went over a curb. He did some damage to his tires. He was taken to the police station and will have a court date at some point to be determined. He feels very embarrassed about that. He feels very he lucky that he that he did not harm himself or anybody else. Prior to this, within the last couple of months, he had an episode where after drinking alcohol, he was arrested for disturbing the peace and spent a night in jail, as his son

I have left him multiple messages and have called a couple of times only to have the phone disconnected while I am starting to talk to him. I have been concerned in the past about some macrocytosis on the CBC, as well as elevated liver function testing and he is here today to discuss that as well. His GGT shows mild improvement from 145 to 139. High of a normal is 85. CBC still shows a macrocytosis with a MCV of 108, MCH of 36.4, down from 110 and 37.5. He does have a slight elevation in his total bilirubin is 0.3. Other liver function testing is normal. He has previously had a liver ultrasound back in October of 2014, showing hepatic steatosis, otherwise negative abdominal ultrasound. He has previously has declined evaluation by gastroenterology or hematology and he is still not sure that he wants to do that. He is not having any belly pain. No jaundice. He tells me he is eating and drinking. His weight is down from his last, visit six pounds from July. However, up from his first visit with me back in the fall of 2014, up five