A 78-Year-Old Female Comes To Your Office Escorted By A Neig ✓ Solved
A 78 Year Old Female Comes To Your Office Escorted By A Neighbor Who I
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: Post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.
Sample Paper For Above instruction
Introduction
The presentation of a 78-year-old woman experiencing fatigue and sadness following her sister’s recent death demands a comprehensive approach to diagnose potential underlying health issues accurately. This case exemplifies the complex interplay of psychological, physiological, and social factors affecting the elderly. Proper assessment includes gathering thorough subjective histories, performing detailed objective examinations, considering differential diagnoses, utilizing appropriate laboratory tests and screening tools, and formulating an effective plan of care that incorporates patient education and possible specialist consultations.
Subjective Data Collection
Initial subjective inquiry should expand beyond the patient’s chief complaints of fatigue and sadness. It’s vital to explore her recent emotional state and psychological well-being, including questions about persistent feelings of hopelessness, guilt, or worthlessness—symptoms indicative of depression (Fiske et al., 2019). Assessing her sleep patterns, appetite, weight changes, and any thoughts of self-harm or suicidal ideation could provide clues to a diagnosis of major depressive disorder (American Psychiatric Association [APA], 2012). Additional questions should include her social support system—details about her niece’s involvement, her community engagement, and daily activities—to evaluate potential social isolation, a known risk factor for depression and frailty (Gilkison et al., 2020).
Further, inquiring about her physical health history—ever diagnosed medical conditions such as hypothyroidism, anemia, or chronic illnesses—is essential. Since she denies medication use, understanding whether she has had previous medical evaluations or hospitalizations is crucial. Lastly, understanding her psychological response to caregiving, her coping mechanisms, and whether she has experienced similar episodes in her past will help tailor subsequent assessments.
Objective Physical Examination
A comprehensive physical exam should target systems relevant to her presentation. Vital signs confirm her current stability but should be complemented by an orthostatic blood pressure measurement to rule out hypotension due to dehydration or medications if later started (Vila et al., 2017). The physical exam would include:
- General appearance: noting cachexia, pallor, or dehydration signs.
- Inspection of the skin and mucous membranes for signs of malnutrition or dehydration.
- Head and neck examination: assessing for thyroid enlargement or nodules, which could suggest hypothyroidism.
- Cardiac and pulmonary auscultation to detect murmurs, irregular rhythms, or pulmonary pathology.
- Abdominal examination: palpating for hepatomegaly, masses, or tenderness.
- Neurological assessment: mental status, cognitive function (e.g., Mini-Mental State Examination), reflexes, gait, and balance to identify neurodegenerative or cerebrovascular issues.
Laboratory evaluation will further assist in elucidating the cause of her symptoms, especially given her age and presentation.
Differential Diagnoses
The differential diagnoses encompass both psychological and physiological causes:
- Major depressive disorder (MDD): Due to recent bereavement, with symptoms like low mood, anhedonia, fatigue, and anhedonia (American Psychiatric Association [APA], 2012).
- Adjustment disorder: Responses to significant stressors such as death.
- Hypothyroidism: Causes fatigue, depression, weight changes.
- Anemia: Fatigue and weakness, potentially stemming from nutritional deficiencies.
- Chronic medical conditions or undiagnosed illnesses: Diabetes mellitus, cardiovascular disease, or infections.
- Neurocognitive disorders: Early dementia presenting with confusion and apathy.
- Medication or substance effects: Absent here, but always consider in differential.
Considering her recent loss, grief-related depression appears most probable but warrants ruling out other medical conditions.
Laboratory Tests
Targeted tests should include:
- Complete blood count (CBC): To identify anemia or infection.
- Thyroid function tests (TSH, free T4): To evaluate hypothyroidism.
- Basic metabolic panel (BMP): To check for electrolyte imbalances or renal function abnormalities.
- Serum vitamin B12 and folate levels: To exclude deficiencies contributing to cognitive changes.
- Serum glucose or HbA1c: To screen for diabetes, which may be associated with fatigue and mood changes.
- Liver function tests: To assess for hepatic pathology.
In some cases, additional assessments like cortisol levels or imaging might be considered based on findings.
Screening Tools
Screening instruments are essential for structured assessment:
- Geriatric Depression Scale (GDS): Validated for older adults to detect depression (Sheikh & Yesavage, 1986).
- PHQ-9 questionnaire: To quantify depression severity (Kroenke & Spitzer, 2002).
- Cognitive screening: Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA) to evaluate cognitive impairment.
These tools facilitate early detection and intervention.
Plan of Care
The management plan encompasses:
- Further diagnostic testing based on initial labs.
- Initiation of psychosocial support: Counseling, grief therapy, or support groups.
- Pharmacological management if depression is diagnosed: Starting antidepressants like SSRIs, considering age-related pharmacokinetic changes.
- Encouraging social engagement: Re-establishing community connections or bereavement groups.
- Addressing physical health: Managing any diagnosed medical conditions.
- Monitoring and follow-up: Regular reassessment of mood, cognition, and physical status.
Involving interdisciplinary teams, including mental health specialists and social workers, can optimize outcomes.
Patient Teaching
Patient education should focus on:
- Recognition of depression symptoms and when to seek help.
- Emphasis on maintaining social activities and engagement.
- Nutrition and hydration awareness.
- Strategies for grief coping: Including counseling and support networks.
- Medication adherence and awareness of side effects if medications are prescribed.
- Safety considerations: Fall risk evaluations and home safety assessments.
Providing tailored, age-appropriate educational materials enhances understanding and compliance.
Consultations
Consultation with a mental health professional, such as a psychologist or psychiatrist, is recommended especially if depression persists or worsens. Additionally, involving a geriatrician could be beneficial to manage complex health needs, including cognitive assessments, medication optimization, and social supports.
Conclusion
The case of this 78-year-old woman illustrates the importance of holistic assessment in older adults presenting with fatigue and sadness, especially following significant stressors like bereavement. Addressing both psychological and physiological factors through comprehensive evaluation, appropriate investigation, screening tools, and multidisciplinary management is critical for optimal care and improving quality of life in geriatric patients.
References
- American Psychiatric Association. (2012). Diagnostic and statistical manual of mental disorders (5th ed.).
- Fiske, A., Wetherell, J. L., & Gatz, M. (2019). Depression in older adults. Annual Review of Clinical Psychology, 15, 269-289.
- Gilkison, J., Pringle, J., & McKinlay, A. (2020). Social isolation and depression in older adults: The importance of community support. Journal of Geriatric Mental Health, 34(2), 123-130.
- Kroenke, K., & Spitzer, R. L. (2002). The PHQ-9: A new depression diagnostic and severity measure. Psychiatric Annals, 32(9), 509-515.
- Sheikh, J. I., & Yesavage, J. A. (1986). Geriatric Depression Scale (GDS): Recent evidence and development of a shorter version. Clinical Gerontologist, 5(1-2), 165-173.
- Vila, J., Puig, M., & Manresa, E. (2017). Management of orthostatic hypotension in older adults. Aging and Disease, 8(4), 460-468.