Sunday, September 4, 2011

A good reminder

An 84 y/o male, retired pastor, just doesn't feel well.

He reports decreased energy, feeling more fatigued, decreased get up and go, and a decreased desire to be with others.

He came to see me for another medical opinion.

He was cognitively intact.

He reported he went to another primary care physician who did a "boat load" of blood tests and sent him for a total body CT scan. He also had an MRI of his brain. He reports that nothing abnormal was found.

He reports that he saw a cardiologist who put him through a bunch of tests. Everything turned out fine.

A pulmonologist had him get pulmonary function tests and a sleep study. Both did not show any significant findings.

Me: What are your symptoms again?

Patient: I just don't feel well, I tire easily, I have no energy, no desire to socialize; I even stopped writing which has always been a joy of mine.

Me (and I don't pretend to be the smartest guy around): It sounds like you might be depressed.

I then went on a discussion of possibly trying an anti-depressant that would increase brain neurotransmitters, including serotonin.

I actually couldn't think of anything else to do that already hadn't been done by the other physicians.

Patient: You know my son has been using a medication that increases serotonin for awhile and has been doing great since he started taking it.

On phone follow-up three weeks later he reported he was starting to feel a lot better.

I'll be the first to admit that I've often made depression a diagnosis of exclusion after ruling out other medical conditions.

I'm not sure, but I suspect since he was a retired pastor, the other physicians didn't think he could be susceptible to depression.

Fear of litigation is often used as an excuse for so may tests being done.

It was clear that this man was not a litiginous person.

In hind sight, it obvious that depression should have been considered earlier in his medical work-up given his presenting symptoms.

One SSRI is on the Wal Mart $4/month ($10/3 month) plan.

He had over $10,000 in tests before this option was considered.

It's a good reminder to all, including myself!

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