Meet Mr. Hake. He is a 62-year-old male well-known to you who comes to the clinic for a 6-month follow up of his diabetes, hypertension and hyperlipidemia. He also has a history of stage II diastolic dysfunction. All of his medical problems are typically well-controlled which is why you are surprised when you receive his chart and see that his blood pressure today is 166/92 and his fingerstick blood glucose is 278. Upon questioning, he tells you that he is taking all of his usual medicines but is feeling fatigued & not sleeping well. He denies chest pain, peripheral edema, orthopnea, paroxysmal nocturnal dyspnea, shortness of breath, polyuria and polydipsia. His vitals reveals a 10-pound weight loss, a regular pulse of 88 and an oxygen sat of 98%. The rest of his exam is unremarkable except that his affect is sad and he is more withdrawn than usual.
What should you do next? More than one response may be correct.
a. Screen Mr. Hake for depression by asking him about his mood and interest in his usual pleasurable activities
This is a reasonable next step given that depression can complicate chronic disease management in a variety of ways. Depression screening can be achieved a number of ways including simply asking all the SIG-E-CAPS questions.
b. Screen Mr. Hake for alcohol and drug use
This is a reasonable next step given that substance use can complicate chronic disease management in a variety of ways. Substance use screening can be achieved in a number of ways, including formal screening instruments that are verbally or self-administered or by simply asking about usage – including frequency of use and amounts – during the interview in non-judgmental way.
c. Perform a urine drug screen
Though performing a UDS could help confirm suspicions about the use of certain substances, it is problematic as an alternative to an honest & open patient interview. Establishing trust with a patient and speaking openly about substance use can not only allow you to get more accurate information about use patterns, but it can also lay the groundwork for patients to consider further treatment for a substance use problem.
d. Refer Mr. Hake to a mental health counselor
This may eventually be a reasonable choice, however, the referral is premature as a more thorough history focusing on mood, substance use, and other information should precede a referral of this kind.
e. Increase Mr. Hake’s antihypertensive medications and schedule a follow-up visit to review blood pressure and blood glucose in 2 weeks
As with any chief complaint, the problem of chronic disease exacerbation should be explored and a differential diagnosis made before a treatment is chosen. What are the most likely reasons for the change in Mr. Hake’s status?