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A Case of the Dwindles


A 70 year old presents with apathy and depression. Diagnosis please.

Dear Dr. Meyers,

Thank you for your kind referral of Dr. Private Practitioner (PP). She was seen in our group clinic on Dec. 1, 2014, for evaluation and treatment.

Chief complaint: Dr. PP is 70 years old who has a chief complaint of “things aren’t just fun anymore.”

History of present illness: She was in a usual state of good health until about 5 years when she started experiencing anxiety, loss of appetite, social isolation, depression and weight loss. She denies any significant trauma, excessive drug use or chronic illness, but claims “they are just moving my cheese and I don’t know what to do about it.” This has affected her general approach to her practice and personal life to the extent that she is considering abandoning private practice to pursue other non-clinical careers.

Past Medical History: Up to about 5-6 years ago, she felt healthy and had a generally positive attitude, which has progressively deteriorated. Revenues are dropping, expenses are increasing, she feels she is losing control and no longer feels she is appreciated by her patients or society. She has had minor surgery on her revenue cycle management systems and has dabbled in EMRs.

Social History: Denies smoking, although has been consuming more alcohol lately. She is experimenting with marijuana, which is legal in her home state of Colorado. She is in counseling for her marriage to society.

Family History: Several doctors in her family who have since retired and glad they did.

Travel History: Has done several medical missions to “reconnect” but denies travel to Ebola endemic countries.

Review of Systems: Non-contributory.

Physical Exam: Pulse: 120 and weak, Resp 30/min, BP 140/92, Temp: 98.7

The patient looks older than her stated age. Physical exam was essentially normal except for mental status exam that revealed some mild-moderate confusion.

Assessment: 1.Grief reaction to the changing healthcare environment with signs and symptoms of the dwindles (adult failure to thrive syndrome).

2. Borderline hypertension

3. Anxiety

Plan: As you know, the dwindles are characterized by (1) deterioration in the biologic, psychologic, and social domains; (2) weight loss or undernutrition; and (3) lack of any obvious explanation for the condition. In addition. Dr. PP seems to be suffering from the expected pattern on grief experienced by those who lose someone or something they love i.e. denial, anger, bargaining, depression, and acceptance. Most of the other private practitioners I’ve seen with a similar condition are stuck in the anger phase and having difficulties moving forward. As I’m sure you are aware, to date, there are no drug or surgical treatments for the disorder, however, I am prescribing a trial of Othercare for your patient.

This is a complex, multifactorial disease with a guarded prognosis. Should your patient take the necessary steps to adapt to change, innovate and have a more positive attitude, then she is likely to recover nicely and thrive. The emphasis in the initial stages of treatment should be adequate emotional, financial, and social nutrition. If, on the other hand, she continues to deny the reality of what is happening, deny personal responsibility for what has occurred and is persistently angry, then I’m afraid there is not much we can do for her.

We have recently become aware of some experimental therapies that have not been as yet clinically validated or cleared. These include electronic medical records, digital health technologies, new care delivery models, several new payment schemes that bypass third party payers, part-time jobs, telework, and many others in the pipeline that might benefit your patient in the future.

Thank you again for the opportunity to see your patient and please let us know if we can be of any further help.

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