Posted: October 26th, 2023

A 78-year-old female comes to your office escorted by a neighbor

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?

Should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.

What additional subjective information will you be asking the patient?
Some additional subjective information I would ask the patient includes: her living situation and support system, appetite and diet, sleep patterns, mood changes, stress levels, ability to perform activities of daily living independently, history of falls, substance use, and family medical history. Understanding these social and lifestyle factors is important for developing a holistic treatment plan.
What additional objective findings would you be examining the patient for?
I would examine the patient’s vital signs again to check for any abnormalities, listen to her heart and lungs, feel her abdomen for any masses or tenderness, check her skin for signs of dehydration, and perform a brief cognitive assessment using the Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975) to screen for possible dementia.
What are the differential diagnoses that you are considering?
Some potential differential diagnoses to consider based on the information provided include depression, malnutrition, dehydration, infection, anemia, thyroid dysfunction, heart failure, and early-onset dementia (American Psychiatric Association, 2013; Centers for Disease Control and Prevention, 2019).
What laboratory tests will help you rule out some of the differential diagnoses?
Initial laboratory tests that could help rule out some differentials include a complete blood count (CBC) to check for anemia or infection, basic metabolic panel (BMP) to check electrolytes and kidney/liver function which could indicate dehydration, thyroid stimulating hormone (TSH) level to check for thyroid dysfunction, and troponin level to check for possible heart damage associated with heart failure (Loeb et al., 2019; Qaseem et al., 2017).
What screening tools will you select to use on this patient?
In addition to the Mini-Mental State Examination mentioned earlier, I would administer the Patient Health Questionnaire-9 (PHQ-9) to further evaluate her reported sadness and screen for clinical depression (Kroenke et al., 2001). The PHQ-9 is a brief, valid, and reliable screening tool.
What is your plan of care?
My plan of care would be to treat any underlying medical issues found, provide supportive counseling and resources to help cope with her grief and loss, ensure she has social support in place, screen for and address any functional/cognitive impairments, and consider a referral to psychiatry if depression is indicated on further evaluation and screening. Close follow-up would also be important to monitor her response to treatment and make any necessary adjustments.
What additional patient teaching may be needed?
The patient may benefit from education on healthy diet and hydration, stress management techniques, fall prevention strategies, and available community resources like meal delivery programs or support groups. It would also be important to provide information on the grieving process and normalizing some of the emotions she is experiencing with the recent loss of her sister.
Will you be looking for a consult?
Based on the available information, I do not think a consult is immediately needed. However, if further evaluation reveals more complex medical, functional, or psychiatric issues, I may request consults from relevant specialties like cardiology, nutrition, social work, or psychiatry to help optimize her care plan. Close monitoring is important at this stage.

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