Respond to discussion
Respond to discussion
Subjective Information to Be Gathered
To accurately diagnose the 78-year-old and formulate a comprehensive care plan, it is crucial to inquire about additional subjective and objective information on top of the patient’s complaints (Mason et al., 2020). The additional subjective information I will obtain from the patient is the duration and severity of fatigue, her medical history, changes to her sleeping pattern, and her appetite. Also, I will ask if the patient has had any past mental health disorders or any references to psychiatric treatment. Another crucial subjective information to gather is whether the patient has a social support system.
Objective Findings to Be Examined
In addition to the vital signs presented by the patient, I will conduct physical and medical examinations to examine objective findings such as general appearance, gait, posture, walking, and general hygiene (Ma et al., 2020). I will also conduct physical examinations and assess the patient’s neurological functioning, focusing on neurological deficits and abnormalities in her reflexes. I will also examine her mental health status, nutritional status, functional and occupational assessment, and musculoskeletal system function.
Differential Diagnoses
Based on the patient’s clinical manifestation and the physical assessment, the primary differential diagnoses include major depressive disorder because she lost her sister recently and showcasing fatigue, sadness, and confusion (Liu et al., 2021). Other diagnosis possibilities include bereavement-related adjustment disorder, which can be explained by the sudden change in her health following the death of her sister. The patient’s complaints of reduced appetite and self-neglect are critical indicators of possible malnutrition and dehydration, thus potential differential diagnoses. Other potential differential diagnoses include anemia, hyperthyroidism, and cardiovascular diseases.
Laboratory Tests to Rule Out Some of the Differential Diagnoses
I will utilize several laboratory assessments and tests to rule out some differential diagnoses (Liu et al., 2021). I will conduct serum albumin level tests to rule out potential malnutrition or dehydration cases. A complete blood count will determine the patient’s iron status concerning potential anemia. Other tests to rule out differential diagnoses are thyroid-stimulating hormone tests and lipid profiling for hyperthyroidism and cardiovascular infections.
Screening Tools to be Utilized on the Patient
The patient must be screened to assess whether she has suspected health conditions. I shall utilize a Geriatric Depression Scale (GDS) to screen the patient for significant depression disorders and the severity of the condition (Ma et al., 2020). An additional screening tool I shall utilize is the mini-nutritional assessment (MNA) tool to assess the patient’s nutritional and hydration status. An Instrumental Activities of Daily Living (IADL) tool will determine the patient’s functional and occupational capabilities. MMSEs are recommended as screening tools for assessing a patient’s cognitive functioning and well-being.
Plan of Care
The care plan is intended to address immediate psychological health concerns and formulate a long-term care plan (Mason et al., 2020). I shall offer supportive counseling and empathy to address the patient’s fatigue and sadness. The other part of the plan of care will be ordering laboratory tests to detect any underlying health conditions the patient might be suffering from. Additionally, I shall oversee the patient using self-care techniques and formulate a working follow-up plan.
Additional Teachings and Consultation
Additional teachings I shall provide the patient include the essence of self-care, including proper nutrition, hydration, and rest (Mason et al., 2020). During the treatment, I will teach the patient strategies for managing stress and improving coping skills. As a final teaching component, I will provide information on local grief support groups and counseling services. Regarding consultation, the core practitioners I can consult with are a psychiatrist for mental health assessment and a nutritionist for evaluation and guidance on optimizing nutritional intake.
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