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INSTRUCTIONS FOR THE DOCTOR

This is a short case.

Please take a history from Phyllis and outline to her the most likely diagnosis. Negotiate an initial management plan with Phyllis.

Scenario

You have been called to see Phyllis Brown, aged 74, at home. She has not attended the practice since her husband, Ernie, died two years ago. Ernie and Phyllis were very close and did everything together. They were involved in the local bowling club and seemed to almost live there.

Ernie died suddenly of a heart attack at the club one day and Phyllis took it badly. She now relies on most of her shopping being delivered or done by her daughter. The daughter has asked for this visit as she feels that her mother needs a good check-up.

The following information is on her summary sheet:

  • Past medical history

  • Cholecystectomy 1994

  • Medication

  • Nil

  • Allergies

  • Nil known

  • Immunisations

  • Nil known

  • Social history

  • Widowed

  • Non-smoker.

INSTRUCTIONS FOR THE PATIENT, PHYLLIS BROWN

You are 74 years old and were widowed two years ago. You and Ernie had a good marriage and you find it hard without him. Most of the time you manage at home on your own but going out is impossible. As soon as you know you have to go out, you get anxious. Your heart races and you get diarrhoea. You start to shake and feel a lump in your throat. At times it even becomes difficult to breathe. As soon as you decide not to go out, everything calms down and you feel much better.

As a result you are staying home more and more. Life is just easier when you don’t try to go out. You have adapted by using the phone to pay bills and your daughter has been good about helping with the shopping. Your daughter is concerned that you have not had a check-up with the doctor and so has persuaded the GP to do a home visit.

You would like to go out as you miss your friends but feel helpless and do not know how to get over your problems.

The following information is on your medical record:

  • Past medical history

  • Cholecystectomy 1994

  • Medication

  • Nil

  • Allergies

  • Nil known

  • Immunisations

  • Nil known

  • Social history

  • Widowed

  • Non-smoker.

SUGGESTED APPROACH TO THE CASE

Introduction, establish rapport

Open-ended questions to explore Phyllis’s concerns about her situation.

Specific questions

Establish history of agoraphobia (anxiety regarding public places)

Explore bereavement and possible prolonged grief reaction

Exclude depression

Confirm diagnosis and possible link to grief.

SUGGESTIONS FOR THERAPY

Psychological—grief counselling, relaxation techniques, anxiety management, cognitive behavioural therapy, ...

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