A 78-year-old female comes to your office escorted by a neighbor who is a patient of yours. The neighbor, who has lived next door to the older woman for years, relates that a week ago the elderly woman’s sister died and that she had been her caregiver for many years. The neighbor relates that although she would occasionally see the older woman, she did not visit the home. At the funeral last week, she noticed that the woman appeared fatigued, confused, sad, and gaunt in appearance. Later the neighbor approached the woman, inquired about her health, and determined that the woman had a very difficult time the past couple of months, caring alone for her sister until the end when hospice care was initiated. The neighbor convinced the woman to seek medical care and today is the first appointment with a provider that this 78-year-old female has had in 3 years. The older woman states that she is very fatigued and sad over the loss of her sister. Neither her sister nor the patient has been married. A distant niece came to the funeral but lives about 30 miles away. The woman states that she is not taking any prescription medication and relates no medical problems that she is aware of being diagnosed.
Vital signs: T 97.6°F, HR 98, RR 22, BP 95/60, BMI 21
Chief Complaint: Fatigue and sadness over the death of her older sister.
Discuss the following:
1) What additional subjective information will you be asking the patient?
2) What additional objective findings would you be examining the patient for?
3) What are the differential diagnoses that you are considering?
4) What laboratory tests will help you rule out some of the differential diagnoses?
5) What screening tools will you select to use on this patient?
6) What is your plan of care?
7) What additional patient teaching may be needed?
8) Will you be looking for a consult?
Submission Instructions:
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- Please post your initial response by 11:59 PM ET Thursday
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- Additional subjective information to ask the patient:
- Duration and severity of fatigue and sadness.
- Any changes in sleep patterns, appetite, or weight.
- Presence of any physical symptoms such as pain, weakness, or loss of energy.
- History of any chronic medical conditions or previous diagnoses.
- Family history of medical or psychiatric conditions.
- Social support system and living situation.
- Any recent stressful events or changes in her life.
- Use of alcohol, tobacco, or recreational drugs.
- Current level of daily functioning and activities of daily living.
- Assess for suicidal ideation or thoughts of self-harm.
- Additional objective findings to examine the patient for:
- General appearance and behavior, including signs of depression or distress.
- Mental status examination to assess cognitive function, memory, and mood.
- Physical examination to assess overall health, including vital signs, signs of dehydration, nutritional status, and signs of physical illness.
- Assessment of weight loss or changes in body mass index (BMI).
- Examination of the cardiovascular system, respiratory system, and gastrointestinal system for any abnormalities or signs of underlying medical conditions.
- Neurological examination to assess coordination, reflexes, and signs of neurological disorders.
- Assessment of the patient’s functional status, including mobility and balance.
- Differential diagnoses to consider:
- Major depressive disorder: The patient’s symptoms of fatigue, sadness, and weight loss could be consistent with depression, especially considering the recent loss of her sister and her role as a caregiver.
- Bereavement-related depression: Grief following the death of a loved one can sometimes manifest as depressive symptoms.
- Malnutrition/malnourishment: The patient’s gaunt appearance, weight loss, and fatigue may indicate nutritional deficiencies due to poor eating habits or inadequate dietary intake.
- Chronic medical conditions: Underlying chronic illnesses or undiagnosed conditions could contribute to the patient’s symptoms.
- Thyroid dysfunction: Hypothyroidism can cause fatigue, depression, and weight changes and should be considered as a potential cause.
- Laboratory tests to rule out some of the differential diagnoses:
- Complete blood count (CBC) and comprehensive metabolic panel (CMP) to evaluate for anemia, electrolyte imbalances, liver and kidney function, and other potential abnormalities.
- Thyroid-stimulating hormone (TSH) and free thyroxine (T4) levels to assess thyroid function.
- Vitamin D and B12 levels to check for nutritional deficiencies.
- Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to screen for inflammation or underlying infections.
- Urinalysis to evaluate kidney function and rule out urinary tract infections.
- Screening tools to consider using on this patient:
- Geriatric Depression Scale (GDS): This self-report questionnaire can help assess the severity of depressive symptoms in older adults.
- Mini-Mental State Examination (MMSE): A brief cognitive screening tool to assess cognitive impairment.
- Nutritional screening tools: Assessing the patient’s dietary intake and nutritional status can be done using tools like the Mini Nutritional Assessment (MNA) or the Malnutrition Universal Screening Tool (MUST).
- Plan of care:
- Assess the patient’s immediate safety and ensure she has a support system in place.
- Address any urgent medical needs and provide appropriate treatment or referrals.
- Conduct a thorough evaluation of the patient’s physical and mental health, including a comprehensive history, physical examination, and relevant laboratory tests.
- Treat any underlying medical conditions and manage symptoms such as fatigue and sadness.
- Provide psychoeducation and support regarding grief and loss, potentially referring the patient to a bereavement support group or counselor.
- Consider pharmacological treatment for depression if warranted, involving the patient in shared decision-making and discussing potential risks and benefits.
- Develop a follow-up plan to monitor the patient’s progress, adjust treatment as necessary, and ensure continuity of care.
- Collaborate with other healthcare professionals, such as psychologists or social workers, to provide additional support and resources as needed.
- Additional patient teaching that may be needed:
- Educate the patient on the signs and symptoms of depression and the importance of seeking help.
- Discuss the grieving process and provide resources for coping with loss.
- Provide guidance on self-care strategies, including maintaining a healthy diet, engaging in physical activity, and getting adequate rest.
- Encourage the patient to reach out to friends, family, or support groups for social and emotional support.
- Discuss the importance of regular medical check-ups and follow-up appointments.
- Consultation:
- Consider a referral to a psychiatrist or geriatric psychiatrist for further evaluation and management of depression or complex mental health issues.
- Consultation with a registered dietitian may be helpful to address nutritional concerns and provide dietary recommendations.