Case 9: Managing Depression

Mrs Margaret Farlon, a 72 year old woman, is very low in mood and not enjoying her usual activities.  She presented to the Emergency Department with her daughter, Ellen last night as she has now stopped caring for herself.

Ellen said that her mother had become unwell gradually over the past month following an attempted burglary at her flat. She lives alone and was not eating or washing for the past 3 days.  She denies active suicidal ideation but says she wishes she didn’t wake up that morning.

She was dehydrated and given a litre of saline IV in the ED. Her blood tests after this were normal as was her baseline physical examination. Following review by the on call psychiatrist, she reluctantly agreed for informal admission to the Old Age Psychiatry Ward.

You are the junior doctor on the ward looking after Mrs Farlon.  She has not slept well overnight and refused breakfast.  When you assess her she barely responds to you, she looks at the ground and any movements she makes are extremely slow.

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Question 1: What other information might aid in your assessment?

  • HPC: One month ago, Mrs Farlon awoke in the night to the sound of banging.  She was very frightened so she called the police.  They disturbed a man trying to enter her house but he ran away.  Since this time she has had difficulty sleeping.  Her appetite, mood and energy levels have all decreased.  She has felt on edge and prefers to be around others.  She has noticed her mother’s oral intake is very poor and that she is waking up very early.  She says her mother has talked about feeling guilty and thinks that the attempted burglary is somehow her fault, when she talks like this Ellen does not understand what her mother is getting at and cannot reassure her.
  • SHx: Mrs Farlon lives alone since her husband died seven years ago from an MI.  She normally attends coffee mornings at church twice a week and meets with a neighbour to paint once a week.  She is an avid reader and occasionally goes into central London to see a play with her neighbour.  She is normally independent around her ground floor flat. There has been no concerns about her memory.
  • PPHx: Mrs Farlon has a history of one episode of post natal depression after birth of daughter.  Treated successfully by the GP with an SSRI. No other Past Psych history or family history of psychiatric illness.
  • PMHx: She is normally fit and well.  She takes Amoldipine 5mg for high blood pressure and Atorvastatin 20mg.  She has been on these medications for 5 years.  She has no known drug allergies.
  • Substances: She drinks alcohol rarely, only Christmas and birthdays.  She is a non-smoker.
  • Personal Hx: She is a retired English teacher, being born and brought up in North London.  She was an only child to a single mother.  Her father having died when she was just a newborn from unknown causes.  Met and married her husband who was an accountant, when she was 20.  Busy, happy life, quite sociable.

Discuss now on Twitter, using the hashtag #quclms. Follow @quclms for updates. Further information and follow-up questions will appear on Twitter throughout the week.

Question setter & Expert: Dr Clare Wadlow, Psychiatry ST5 & Clinical Teaching Fellow, UCLMS  

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