Discussion 2: Case Study 1

• What additional subjective information will you be asking the patient?

 The patient a 78-year-old female, visits the clinic complaining of being sad and fatigued over the loss of her sister. Gathering subjective data for this patient is an important first step in taking a thorough history. It would be essential for the primary care provider to inquire about how long she has been taking care of her sister, as this may provide understanding to potential diagnosis. Inquiring about when the symptoms began and how they began, whether sudden or slowly over time is also import. Collecting data about psychological health such as sleep pattern, decreased interest in any previous activities, anxiety, depression, and suicidal ideation would be appropriate for a patient in this situation. Other additional subjective data would include recent change in appetite or weight change, financial concerns, and alcohol and drug use. 

What additional objective findings would you be examining the patient for?

         In addition to the vital signs given, a general head-to-toe examination would be performed. Special focus on the patient’s body movement, gait, posture, speech, affect, and hygiene is necessary. Motor differences in depression can include psychomotor agitation, which increases bodily movement, speech, and thoughts, or psychomotor retardation, which slows down these components (Kumar et al., 2021). Given that motor changes directly impact an individual’s overall level of functioning this assessment is crucial. Additionally, assessment of nutritional status and hydration status are of importance since her chief complaint consists of sadness and fatigue.

What are the differential diagnoses that you are considering?

         My differentials for this patient are depression, post-traumatic stress disorder (PTSD), anxiety, and failure to thrive.

What laboratory tests will help you rule out some of the differential diagnoses?

           Some of the necessary laboratory tests to carry out include complete blood count to rule out anemia and infection, basic metabolic panel to check electrolyte levels, kidney and liver function to rule out encephalopathy and dehydration, and a toxicology screening for any drug abuse or poor medication management.

What Screening tools will you select to use on this patient?

Two of the screening tools for this case I would select are the Patient Health Questionnaire-9 (PHQ-9) which is a self-administered tool used to screen, diagnose, monitor, and measure the severity of depression and The Generalized Anxiety Disorder Assessment (GAD-7) which is a self-reported questionnaire for screening and severity measuring of generalized anxiety disorder (Maruish, 2017).

What is your plan of care?

The plan of care would encompass various strategies to aid in resolving the patients’ grief. It is important for this patient to understand depression and provide her with strategies on how she can cope with the issue. The patient would be encouraged to follow up for laboratory results and regular examinations.

What additional Patient Teaching may be needed?

Additional patient teaching would include instructions to notify any health care provider immediately if thoughts of suicide occur. Other education would include a healthy diet and exercise plan.

Will you be looking for a consult?

A consult to a home health would be appropriate since this patient does not have a good support system. Home health services include monitoring the patient’s nutritional status, vital signs, medications, and home safety. Coordination of care and regular communication is done to ensure an effective plan of care remains in place (U.S. Centers for Medicare and Medicaid Services. (n.d.). A consult to mental health services such as counseling and psychiatry would also be applicable if the patient has persistent depression and unresolved grief.

References

Kumar, D., Villarreal, D. J., & Meuret, A. E. (2021). Walking on the bright side: Associations between affect, depression, and gait. PLoS one, 16(12), e0260893.

Maruish, M. E. (Ed.). (2017). Handbook of psychological assessment in primary care settings. Taylor & Francis.

U.S. Centers for Medicare and Medicaid Services. (n.d.). What’s Home Health Care? Retrieved March 22, 2022, from https://www.medicare.gov/what-medicare-covers/what…