6001-W4-D13
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Fazaia Degree College, M.R.F, Kamra, Attock *
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Course
6001
Subject
Medicine
Date
Nov 24, 2024
Type
docx
Pages
3
Uploaded by maryamberlas
1.
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.
From the case study, Aquifer, (n.d.), Mrs. Gomez's chief complaint is that for six months has been
having trouble sleeping. She has trouble staying asleep and wakes up after a few hours. She
doesn't have any pain, breathing problems, or restlessness while she sleeps. Over-the-counter
medicines like Flor de Tila and Tylenol PM didn't help. Her sleep problems aren't caused by
things in her surroundings, like noise or an uncomfortable place to sleep. She moved in with her
daughter after her husband died, which is a recent change in her life. She has become less
involved with her friends and family, going to church less and losing interest in things she used to
enjoy. Mrs. Gomez's daughter wrote in the family history that she noticed her mother moving
more slowly, being less active, and looking depressed. Chronic diseases like high blood pressure,
Type 2 diabetes, and high cholesterol are part of a person's medical background. So are surgeries
like cholecystectomy and hysterectomy. Mrs. Gomez takes many medicines to control her
diabetes, high blood pressure, and cholesterol. She also takes aspirin to prevent heart disease
and calcium with vitamin D to prevent osteoporosis (Aquifer, n.d).
2.
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? Physical Exam:
As part of Mrs. Gomez's physical examination, her vital signs (temperature, blood pressure, heart
rate, and breathing rate) are checked, as well as her general appearance, which shows that she is
tired and moving slowly (Auquifer, (n.d.). The head, eyes, ears, nose, and mouth (HEENT) are
also checked, as well as the heart and lungs, the abdomen, and the brain for signs of depression
(Auquifer, (n.d.). A full study of systems looks at constitutional symptoms and different organ
systems. Blood tests, like a hemoglobin A1c test to see how well diabetes is controlled, and the
Geriatric Depression Scale - Short Form (GDS-SF), with a score of 9 indicating depression, are
used for diagnosis (Dunphy et al., 209 p. 1105). The Mini-Cog test is within the normal range, so
it doesn't show dementia. A tool called the PHQ9 (Patient Health Questionnaire-9) is used to find
out how often depressive signs have happened in the last two weeks (Dunphy et al., 2019, p.
1105). It's easy for the patient to fill out in the waiting room or exam room before their general
care visit, and it gives a quick picture of their mental health. The PHQ-9 can also be used to keep
track of treatment success at follow-up appointments. The Quick Inventory of Depressive
Symptomatology (QIDS-SR) is another test that can be used to track symptoms and see how they
change over time (Dunphy et al., 2019, p. 1100). It is sensitive to changes that happen because
of treatment. As extra tools, a mental status exam can be used to check how well the brain is
working, and a sleep log or actigraphy could be used to get more specific information about how
people sleep (Fekedulegn et al., 2020). Actigraphy is a non-invasive method of monitoring and
recording a person's activity levels and rest periods over an extended period (Fekedulegn et al.,
2020). It involves using a small, wrist-worn device called an actigraph, which typically contains an
accelerometer. The accelerometer detects and records movements, providing information about
the individual's sleep-wake patterns and overall activity (Fekedulegn et al., 2020).
Differential Diagnoses:
1.
Major Depressive Disorder:
2.
Mrs. Gomez has a low mood, anhedonia (loss of interest), changes in energy, sleep habits,
and psychomotor retardation (slow movements), all of which are signs of depression
according to Dunphy et al., (2019)
3.
Grief Reaction:
Recent bereavement, alterations in living situation, and manifestations of sorrow and
mourning. Grief may present itself through sleep disruptions, alterations in energy levels,
and a diminished inclination towards formerly enjoyed activities (Dunphy et al., 2019, p.
1060).
4.
Hypothyroidism:
Substantial research highlights the correlation between hypothyroidism and depression
(Nuguru et al., 2022). The standard approach to treatment typically involves administering
thyroid replacement therapy and, when necessary, antidepressant medications (Nuguru et
al., 2022). The inclusion of levothyroxine is known to enhance the efficacy of
antidepressants, augmenting their ability to treat and alleviate depressive symptoms
(Nuguru et al., 2022).
Final Diagnosis:
Major Depressive Disorder (MDD):
The final diagnosis for Mrs. Gomez was major depressive disorder. A comprehensive diagnostic
process, including a thorough system review and vital signs assessment, played a crucial role in
understanding her overall health and excluding underlying medical issues. These examinations
were instrumental in ruling out specific medical illnesses, thereby validating the diagnosis of
severe depressive disorder (Dunphy et al., 2019, p. 1105). The determination was based on the
Geriatric Depression Scale questionnaire, an unremarkable physical exam, and insights from her
recent social and family history (Dunphy et al., 2019, p. 1105). Additional laboratory tests were
ordered to further investigate and rule out any other potential causes.
5.
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?
A multifaceted care plan has been outlined for Mrs. Gomez, addressing her depression
through both drug and non-pharmacological interventions. The initiation of sertraline at 25
mg daily is recommended, with close monitoring for side effects, particularly nausea
(Dunphy et al., 2019, p. 1100). Adjustments to diabetes medication may be considered
based on hemoglobin A1c results. Non-pharmacological strategies involve encouraging
regular exercise, such as walking at the local mall, and emphasizing engagement in enjoyable
activities (Dunphy et al., 2019, p. 1100). Patient education is a key component,
encompassing discussions about depression as a medical condition, information on
sertraline's purpose and potential side effects, and the importance of follow-up
appointments (Dunphy et al., 2019, p. 1100). A two-week follow-up is scheduled to monitor
progress, address concerns, and reinforce mental health resources. Additionally, a referral to
mental health and community services is proposed for ongoing support, and involving a
counselor is considered to address emotional aspects of grief (Dunphy et al., 2019, p. 1100).
This comprehensive approach underscores the commitment to Mrs. Gomez's well-being and
the importance of continuous collaboration with mental health resources for her ongoing
care.
Reference Aquifer. (n.d.). Family Medicine 03: 65-year-old female with insomnia.
https://southunur.meduapp.com/document_set_document_relations/30223
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary Care (5th
ed.). F. A. Davis Company.
https://digitalbookshelf.southuniversity.edu/books/9781719640282
Fekedulegn D Andrew M E Shi M Violanti J M Knox S & Innes K E (2020) Actigraphy
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