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Question 1
The patient comes into the medical facility explaining that he is struggling to sleep. The patient can only sleep for a few hours and the patient explains that there is no discomfort like pain or breathing problem. the patient also rarely consumes alcohol or caffeine. Also, there are no environmental factors that may be contributing to the problem. is no longer attending church or doing activities like reading which she once enjoyed.
Social: the patient lost her spouse of 30 years and has been living with her daughter and son in law.
PMH: type 2 diabetes, hypertension, and hypercholesterolemia.
surgical history: hysterectomy due to fibroids and cholecystectomy.
Medication: methyldopa (250 mg bid) and lisinopril (10 mg daily) for blood pressure; glyburide (10 mg daily) and metformin (1,000 mg bid) for diabetes; aspirin (81 mg daily) for CHD prophylaxis; calcium citrate with vitamin D (600 mg/400 IU bid) for osteoporosis prevention; diphenhydramine; and herbal zapote tea.
Question 2
The following are the tests for the patient:
Vitals
HEENT
Pain
Cardiac
Respiratory
Abdominal
Neurologic
Diagnostic tests
To diagnose the patient with depression. They need to meet the following symptoms criteria
The need to either be depressed mood or loss of interest or pleasure/
They also need to have at least 4 of the following symptoms
Insomnia, loss of interest, guilt, decreased energy, reduced concentration, loss of appetite, psychomotor retardation, or suicidal ideation.
Screening for dementia to use mini-cog exam and mini-mental state exam, depression screening through use of PHQ-9.
It is also important to ask patient about the level of zapote tea as it is associated with reduced blood pressure.
Question 3
Differential diagnosis
Hypothyroidism. This affects 5% of the people in the USA. Checking levels of thyroid stimulating hormone can help with diagnosis and the problem is treated using thyroid-replacement medications. This problem can result in depression but when the levels of thyroid stimulating hormone are brough back to normal depression subsides.
A second disease is Parkinson disease where more than half of those with this disease report suffering from moderate symptoms of depression. Therefore, any patient that has depressive symptoms who starts developing movement problems should be evaluated to rule out Parkinson disease.
The third disease is dementia which may be hard to differentiate from depression. They present similar symptoms such as being slow, confused, unresponsive, and forgetful. The MMSE (Mini-Mental State Examination) assessment can be used to assess cognitive skills in people where dementia is suspected.
Question 4
Management of the problem
Medication is an option for treatment of depression where the patient is to take medication for 9 to 12 months because stopping can result in higher risk of recurrence. Some of the medication to consider for the patient include SSRIs and SNRIs (Heidelbaugh, 2021). Also, psychotherapy is a good treatment option for the patient and especially cognitive behavior therapy. The patient should also engage in exercises and avoid substance abuse.
References
Hay, W., & Seagrave, M. (n.d.). Family medicine 03: 65-year-old female with insomnia. South University College of Nursing and Public Health Graduate Online Nursing Program. https://southu-nur.meduapp.com/document_set_document_relations/30223
Heidelbaugh, J. J. (2021). Depression: A multidisciplinary approach, E-book: Clinics collections. Elsevier Health Sciences.
Peer 2
Discuss the Mrs. Gomez’s history that would be pertinent to her difficulty sleeping. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.
Mrs. Gomez visited the clinic with chief complaint of insomnia, difficulty concentrating and feeling low all the time. She previously used to go to church three to four times a week but now she remains at home all the time. She told that she feels bas about being out of focus and not able to help in house chores anymore. She has started watching television all the time and eats junk food. She is least worried out her health and feels devastated emotionally. Her past medical history shows a wide range of problem lists including hypercholesterolemia, Type 2 Diabetes, and Hypertension. She has two surgeries in the past i.e. cholecystectomy and hysterectomy due to fibroids. Her medication history reveals that she is taking glyburide and metformin for diabetes, methyldopa and lisinopril for blood pressure, and atorvastatin for cholesterol. She is also taking CHF prophylactic medication aspirin, calcium citrate with vitamin D for prevention of osteoporosis. She does not smoke and drinks alcohol occasionally. Her family history reveals that she has recently lost her husband and has shifted to her daughter’s house, both of which have disturbed her emotionally. Her inability to focus, lethargy, social inactivity and recent emotional trauma are indicative of depression or some neurochemical imbalance (Kok & Reynolds, 2017).
Describe the physical exam and diagnostic tools to be used for Mrs. Gomez. Are there any additional you would have liked to be included that were not?
The general appearance and history-taking of Mrs. Gomez reveals that she has gained 10 lbs in the last six months due inactivity, lack of sleep and eating junk food. She does not have fever or dizziness, and her posture is intact. Her respiratory and cardiac exam is also normal with no signs of edema, shortness of breath and chest pains. Her endocrine exam does not show polydipsia or polyuria, and gastrointestinal exam did not reveal melena, nausea, or bowel habit changes. Her neurologic exam reveals normal gait, alertness, and no episodes of confusion. Hence, patient might not have any neurochemical balance producing insomnia and lethargy. Her respiratory rate is 16 breaths/min, pulse is 60 beats/minute and blood pressure is 128/78 mmHg. Her weight is 84 kgs and height is 163 cm.
Her psychiatric examination for depressed mood revealed insomnia, feelings of guilt and worthlessness, loss of energy, lack of concentration, indecisiveness, and significant weight gain. Her geriatric depression scale score is 9 which confirms the diagnosis of depression because a score of over 5 depicts symptoms of depression. A cognitive exam is also conducted to assess dementia and Mrs. Gomez score was in normal ranges. A complete metabolic exam is also performed to assess electrolyte changes, a TSH to detect hypothyroidism and CBC to assess anemia and vitamin deficiency. All these hormonal and blood abnormalities are also symptomatic as depression (Reynolds, Lenze & Mulsant, 2019).
Please list 3 differential diagnoses for Mrs. Gomez and explain why you chose them. What was your final diagnosis and how did you make the determination?
Many underlying diseases are associated with symptoms of depression and could be a reason apart from psychiatric disorders. A differential diagnosis for Mrs. Gomez may include hypothyroidism, anemia, and major depression. Hypothyroidism can be ruled out by checking the TSH levels in blood and a normal TSH level rules out hypothyroidism as underlying cause of depression. Anemia is also associated with slow heartbeat, lethargy, lack of sleep, irritability and low mood. Mrs. Gomez showed a very high score on depression scale which confirms the diagnosis of depression. Normal TSH levels and CBC count in normal ranges suggests that she is having major depression symptoms due to loss of a loved one and emotional instability (Reynolds et al. 2019).
What plan of care will Mrs. Gomez be given at this visit, include drug therapy and treatments; what is the patient education and follow-up?
Mrs. Gomez is given sertraline 25 mg for insomnia and is briefed about possible side effects of headache, nausea, diarrhea, and sleepiness. Her previous medication list included methyldopa which may be aggravating her insomnia so it is substituted with amlodipine 5 mg. She is asked to have a daily walk to the local mall to remain active (Kok & Reynolds, 2017).
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