Question

Case study

A 76-y.o. female presents with her daughter for refill of her blood pressure medications (HCTZ and atenolol). Her last visit was 6 months ago. Her daughter mentions that she has noticed that her mother is often distracted and her memory “is not as good as it used to be.” She reminds you that the patient’s husband experienced a stroke about 6 months ago and has required moderate assistance from the patient for daily activities, including remembering when to take mediation. The daughter is worried that the patient is depressed by the situation and that both the patient and her husband could suffer if she is unable to be attentive to their needs. While the changes are subtle, she is concerned. The patient agrees that some days things “just seem too much” and that she has lost interest in some of her usual activities, including completing the daily crossword puzzle and playing mahjong with her friends. She has recognized that she needs to be more careful in how she and her husband take their medications, saying “but he takes a bucket load of

pills, and some days I cannot keep them straight.” She agrees she is saddened by her husband’s limitations but is able to help him with his physical function needs and is glad that she is able to help him. She further states that she feels her overall health is good, and she denies dizziness, shortness of breath, chest pain, trouble sleeping, or fatigue. She has some morning joint pain; for

this, she often takes and OTC naproxen.

History of osteoporosis, mild osteoarthritis, allergic to penicillin and unable to tolerate ACE inhibitors. Currently taking HCTZ, Atenolol, Raloxifene, Naproxen, Calcium. Both parents have hypertension, mother with Alzheimer’s dementia onset at 86, sister, depression and breast cancer, both diagnosed “in her 50s”, Daughter, depression recently diagnosed

Pt. has smoked for 20 years, quitting at age 50. No longer drinks alcohol, previously drank one to two times monthly. Has spent less time out with friends over the past few months, although her daughter is available to relieve her and sit with her husband. Since she gets out less, sometimes has some difficulty navigating routes, gets nervous and irritated by traffic.

Physical Examination

Vital signs: BP 150/88, HR 68, HT 63, WT 120 lbs. (10 lb. loss in 6 months).

General: Appropriately dressed and groomed, pleasant, alert and oriented.

CV: No bruits. HR regular, S1/S2 without murmur or extra sounds. Pulses 2+. No edema. Respiratory: Lungs CTA, symmetrical expansion. Mental

status Geriatric Depression Scale: 5.Recalls 1/3 words after CDT with patient

misplacing hours to mainly locate along lower section of face and reversing hour/minute hands for time (3:15)

Identify three conditions that you would consider in your differential diagnosis, with the most likely condition listed first. Provide rationale for each differential with supporting evidence from the case study.

What further history, further examination, and diagnostic studies should be considered in order to explore your differential diagnosis and confirm your suspicions?

Answer 1

• The three conditions that seem plausible are: depression(has lost interest in daily activities and also there is family history), dementia(history of dementia in mother), anxiety ( gets scared of horns and noise in traffic)
• Ask more about her psychological status, her routine activities, how she feels etc for depression. For dementia, thorough history will do.