Patient is a 69-year-Old male who is refusing treatment for cancer. The following is a description of the patient.
Primary diagnosis: Malignant Neoplasm of Head, Face and Neck (C76.0) because this is the diagnosis that brought the patient into treatment (Hogston, 1997).
Patient's past medical history: Hypertension, hyperlipidemia, stomatitis, anemia, neutropenia. Patient had right radical neck dissection in 2012.
Current Medications: Carvedilol 12.5 mg. q.d.; Furosemide 40 mg q.d.
Social History: Patient is a former smoker who quit two years ago following cancer diagnosis. He is married with children.
Current Issue: Patient is refusing to engage in further treatment regarding his cancer (chemotherapy and radiation) stating that he is tired of the untoward effects of treatment. Patient wants information regarding other options.
Complicating factors:
A. Patient's family does not agree with his decision to stop treatment.
B. Patient does not have an advanced directive or living will.
7. Possible Secondary Diagnoses:
A. Depressive Disorder (Reactive Depression; F32).
B. Adjustment Disorder with Anxiety and Depressed Mood (Grief Reaction; F43.23)
C. Cognitive Changes due to a General Medical Condition (R41.89).
D. Of course it is possible that there is no secondary diagnosis.
There are several approaches...
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