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Posted: July 12th, 2023

Discussion Post- Gerontology Case 1. A 78-year-old female

Discussion Post- Gerontology Case 1. 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.

Additional subjective information to ask the patient:
Detailed medical history: Inquire about any past medical conditions, surgeries, or hospitalizations. Ask if the patient has been diagnosed with any chronic illnesses or mental health disorders.
Medication history: Ask about any over-the-counter medications, supplements, or herbal remedies the patient may be taking.
Review of systems: Ask about any specific symptoms or changes in appetite, sleep, weight, bowel movements, or urinary habits. Inquire about any cognitive changes, memory problems, or difficulty with daily activities.
Social history: Explore the patient’s living situation, social support system, and any recent life changes or stressors. Assess for any history of substance abuse or tobacco use.
Functional assessment: Assess the patient’s ability to perform activities of daily living (ADLs), instrumental activities of daily living (IADLs), mobility, and fall risk.
Emotional and psychological assessment: Evaluate the patient’s mood, affect, and overall mental well-being. Inquire about any history of depression, anxiety, or other mental health concerns.
Additional objective findings to examine the patient for:
General physical examination: Assess the patient’s overall appearance, nutritional status, and hydration. Look for signs of fatigue, cachexia, or weight loss. Evaluate for any signs of distress, pain, or discomfort.
Neurological examination: Assess cognitive function, including orientation, memory, attention, and executive function. Evaluate gait, balance, and coordination. Perform a mini-mental state examination (MMSE) or other cognitive screening tool.
Cardiovascular examination: Check for orthostatic hypotension by measuring blood pressure and heart rate in both supine and standing positions.
Respiratory examination: Evaluate respiratory rate, breath sounds, and signs of respiratory distress.
Musculoskeletal examination: Assess joint mobility, muscle strength, and signs of musculoskeletal abnormalities or deformities.
Skin examination: Look for signs of dehydration, poor skin turgor, bruising, or wounds.
Review of systems: Systematically examine each body system based on the patient’s presenting complaints and medical history.
Differential diagnoses to consider:
Acute grief reaction: The patient’s fatigue and sadness may be a normal response to the recent loss of her sister.
Depression: Symptoms such as fatigue, sadness, and cognitive impairment can be indicative of depression, especially considering the patient’s recent life stressors.
Malnutrition or dehydration: The patient’s gaunt appearance, low BMI, and fatigue may be associated with poor nutrition or inadequate fluid intake.
Physical deconditioning: Prolonged caregiving and lack of physical activity may have led to muscle weakness and fatigue.
Thyroid dysfunction: Hypothyroidism can present with fatigue, weight changes, and cognitive impairment.
Laboratory tests to rule out some of the differential diagnoses:
Complete blood count (CBC): Assess for anemia, infection, or other blood abnormalities.
Basic metabolic panel (BMP): Evaluate electrolyte levels, kidney function, and glucose levels.
Thyroid-stimulating hormone (TSH) and free thyroxine (T4): Rule out thyroid dysfunction.
Vitamin B12 and folate levels: Check for deficiencies that can cause fatigue and cognitive impairment.
Liver function tests: Assess liver function and screen for any liver abnormalities.
Urinalysis: Look for signs of infection or kidney dysfunction.
Depression screening questionnaire: Administer a standardized depression screening tool to evaluate the patient’s mood and mental well-being.
Screening tools to consider using on this patient:
Mini-Mental State Examination (MMSE): Assess cognitive function and screen for possible dementia or cognitive impairment.
Geriatric Depression Scale (GDS): Evaluate the severity of depressive symptoms and screen for depression in older adults.
Activities of Daily Living (ADL) assessment: Determine the patient’s ability to independently perform basic self-care tasks.
Instrumental Activities of Daily Living (IADL) assessment: Evaluate the patient’s ability to perform more complex daily tasks, such as managing medications, cooking, or managing finances.
Plan of care:
Provide emotional support and validate the patient’s feelings of grief and sadness.
Assess the patient’s safety and living situation to ensure she can manage independently or if additional support is required.
Address any immediate health concerns, such as dehydration or malnutrition, through nutritional counseling and hydration support.
Consider a referral to a grief support group or mental health professional to help the patient cope with her loss and address any underlying depression or anxiety.
Develop a comprehensive care plan, including regular follow-up appointments, to address the patient’s physical and mental health needs.
Additional patient teaching may be needed:
Education on grief and bereavement: Provide information about the normal grieving process, coping strategies, and available support resources.
Nutrition and hydration: Discuss the importance of a balanced diet and adequate fluid intake for overall health and well-being.
Importance of social support: Emphasize the benefits of social connections and encourage the patient to engage with friends, family, or community groups for support.
Fall prevention: Provide education on home safety measures, balance exercises, and strategies to minimize fall risk.
Medication management: If necessary, educate the patient on proper medication use, potential side effects, and the importance of regular follow-up with healthcare providers.
Consideration of a consult:
Geriatric psychiatrist: If the patient’s symptoms suggest significant depression or other mental health concerns, a consultation with a geriatric psychiatrist may be beneficial for further assessment and management.
Social worker or case manager: In complex cases where the patient requires additional support, a consultation with a social worker or case manager can help coordinate community resources, provide assistance with long-term care planning, and address any social or financial concerns.

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