Mrs. Maguire never follows my advice completely or takes my prescriptions exactly as prescribed, but she keeps coming back for all her scheduled appointments. She had an unrevealing exam when she came in a few weeks ago with several symptoms. After her pulmonary function test came back abnormal, I gave her a sample of an anticholinergic inhaler two weeks ago and had her take her first dose as I watched. Today I entered the exam room a little bit hopeful that we were getting somewhere.
“I have to be honest with you”, she said. “I haven’t been using the inhaler you gave me, except I tried it again yesterday because I was coming here today.”
“That’s probably not long enough to know if it might help you”, I summed it up. I didn’t ask why she hadn’t really tried it. I sat quietly for a while and then she continued:
“I don’t know what’s wrong with me. I just don’t do anything anymore, only the absolutely necessary. I just have no ambition, and the depression pills you had me try before didn’t help me.”
“Right, you wanted to taper off your Lexapro. How long ago did you actually stop them?”
“Last week, and I see no difference.”
I said nothing.
“You know, ever since Brian and his wife moved to Connecticut two years ago, I haven’t had the ambition to do anything. Babysitting for them was my job, and now I feel so useless. They wanted me to come live with them, but I didn’t like it there at all. I have lived here all my life.”
She teared up.
“I miss my grandchildren.”
“And you miss having a purpose”, I filled in.
“I do”, she said as she pulled a Kleenex from her purse.
“So, have you thought about what other things you could do that would give your days some purpose and structure”, I asked.
“No, like what?”
“Like the food pantry or thrift store or nursing home, maybe giving people rides, I don’t know? Melinda, our social worker, is connected with a lot of places that need volunteers. Would you like to talk with her?”
“A counselor, a psychiatrist? I don’t think I can open up to a stranger.”
“Well, she’s a social worker. She does do counseling, but she also helps people figure things out and make practical decisions, because she knows the community. And you’re telling me what’s going on.”
“Well, that’s different.”
“You don’t have to tell her anything about your feelings if you don’t want. You could just have her help you brainstorm about things you might start doing.”
“I don’t know.”
“Well, think about it. Let me know if you want to talk with her. Otherwise I’ll just see you in three months for your diabetes. But I think it could be good to brainstorm with her.”
“I’ll think about it”, she said as she got up and left the room.
We, or actually she, had finally nailed down her diagnosis and now it is up to her to decide what to do next. I know there is nothing more I could do right now, or is there?
Indeed, these symptoms taken together can make diagnosis quite challenging. I like how you use case studies to encourage clinical reflection.
What’s that saying? You can lead a horse to water but you can’t make him (or her) drink.