Discussion: 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

Discussion: 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

Discussion: 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

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.

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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:
Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

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Additional Subjective Information

            I will ask the patient for additional information. This includes if she is depressed most of the time almost every day, and changes in her sleeping pattern, appetite, and weight. I will also ask her if she feels worthless, guilty, disinterested in pleasure, or experiencing suicidal thoughts, plans, or attempts. I will also ask her about the impact of her current health status on her social, occupational, and other aspects of functioning. I will also find out if the patient has flashbacks, nightmares, or avoidance behaviors. The information will help determine if she has major depression or post-traumatic stress disorder, which could have developed following the loss.

Additional Objective Findings

            Additional objective information should be obtained from the patient. The nurse should document information about the patient’s general appearance. This includes information about her grooming, affect, and weight. A head-to-toe examination should also be performed. This would help rule in or out possible conditions contributing to the patient’s complaints. For example, the presence of trauma marks could indicate violence while a buffalo hump would indicate a metabolic disorder. Assessment findings such as lower limb edema would indicate a kidney problem while the presence of adventitious heart and respiratory sounds on auscultation would mean that the patient has cardiopulmonary problems.

Differential Diagnoses

            One of the differential diagnoses I would consider for the patient is major depression. The patient could be having major depression because of her recent loss. She also has symptoms such as fatigue and sadness, which are seen in patients with major depression. The other differential that would be considered is post-traumatic stress disorder. The patient could have undergone traumatic experiences when caring for her sister. This could have led to post-traumatic stress disorder. The last differential diagnosis would be hypothyroidism. Patients with hypothyroidism experience symptoms similar to those seen in major depression (Dubovsky et al., 2021). As a result, I would consider hypothyroidism a potential differential diagnosis for the patient.

Laboratory Tests

            I would order a complete blood count and thyroid function tests. A complete blood count would help rule out infections as the cause of the patient’s problems. Thyroid function tests will help rule out hypothyroidism if thyroid hormones are within the normal ranges.

Screening Tools

            I will administer the Patient Health Questionnaire-9 (PHQ-9) to the patient. PHQ-9 is a screening tool used to diagnose patients with major depression. It scores various variables associated with major depression. A diagnosis is confirmed if the sum of the items is at least 5 out of 27. A score of 5-9 is considered mild depression, 10-14 for moderate, 15-19 for moderately severe, and 20-27 is considered severe depression (Negeri et al., 2021; Sun et al., 2020).

Plan of Care

            My plan of care for the patient would be prescribing antidepressants for her. The patient appears moderately depressed following her loss. Antidepressants such as selective serotonin reuptake inhibitors would be appropriate for he (Dubovsky et al., 2021)r. I would prescribe oral sertraline 50 mg once daily and a follow-up visit after a month.

Additional Patient Teaching

            I will educate the patient on the importance of treatment adherence. I will inform her that it might take some time before symptoms improve since antidepressants take about 2-6 weeks to produce the desired effects. I will also educate her about the expected side effects such as insomnia and hypotension (Dubovsky et al., 2021). I will inform her to report any adverse effects such as suicidal thoughts, plans, or intents.

Consult

            I will consult a psychiatric nurse practitioner, counselor, and social worker. A psychiatric nurse practitioner and a counselor will help determine the need for additional services such as psychotherapy for the patient. A social worker will help link the patient with social support services that will help the patient recover from her loss.

References

Dubovsky, S. L., Ghosh, B. M., Serotte, J. C., & Cranwell, V. (2021). Psychotic Depression: Diagnosis, Differential Diagnosis, and Treatment. Psychotherapy and Psychosomatics, 90(3), 160–177. https://doi.org/10.1159/000511348

Negeri, Z. F., Levis, B., Sun, Y., He, C., Krishnan, A., Wu, Y., Bhandari, P. M., Neupane, D., Brehaut, E., Benedetti, A., & Thombs, B. D. (2021). Accuracy of the Patient Health Questionnaire-9 for screening to detect major depression: Updated systematic review and individual participant data meta-analysis. BMJ, 375, n2183. https://doi.org/10.1136/bmj.n2183

Sun, Y., Fu, Z., Bo, Q., Mao, Z., Ma, X., & Wang, C. (2020). The reliability and validity of PHQ-9 in patients with major depressive disorder in psychiatric hospital. BMC Psychiatry, 20(1), 474. https://doi.org/10.1186/s12888-020-02885-6