6001-W4-D5

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Fazaia Degree College, M.R.F, Kamra, Attock *

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6001

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Nursing

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Nov 24, 2024

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1.) Discuss 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 is a 65-year-old female who presents to the clinic for complaints of insomnia and fatigue over the past six months. She denies physical symptoms which may be causing her insomnia such as pain or shortness of breath that might be associated with sleep apnea or restless leg syndrome. She also denies the use of caffeine and only drinks alcohol on special occasions such as a holiday. Mrs. Gomez does report that her husband of thirty years died last year, and she has recently moved in with her daughter. She explains that she has had little energy and has lost interest in activities that she used to love such as attending church and reading. The patient’s daughter is present and helps provide this history. Mrs. Gomez past medical history includes type two diabetes, hypertension, and hyperlipidemia (William, 2023). Her only surgical history is a cholecystectomy and a hysterectomy. Mrs. Gomez is taking several different medications. She is taking glyburide 10 mg daily and metformin 1000mg twice daily for her diabetes (William, 2023). During the assessment, her A1C was elevated to 8.7. Mrs. Gomez says she has been eating more junk food and does not have the energy to exercise. It was also noted that she had gained 10lbs since her previous visit. Her other medications include methyldopa 250 mg twice daily (hypertension), lisinopril 10mg daily (hypertension), atorvastatin 80mg daily (hyperlipidemia), aspirin 81mg daily (prevention of coronary artery disease) and calcium citrate with vitamin D (prevention of osteoporosis) (William, 2023). She was also asked about any overthe-counter medications or herbal supplements. She reports taking Tylenol PM which is acetaminophen and diphenhydramine to try to aid in her insomnia. Mrs. Gomez also says she used “flor de tila tea” to try to improve sleep quality. Flor de tila also called linden tea, is made from dried flower and bark of linden trees. Linden tea is frequently used in folk medicine for curing colds, improving sleep, and reducing anxiety. There are few studies that have been conducted that prove that linden tea is effective. It is important to include patients' spiritual and cultural beliefs when developing a plan of care. It is equally important to ensure that any herbal supplements or over-the-counter medications are not negatively interacting with the patients' prescribed medications. Since there is limited scholarly information about linden tea it might be a good idea to discuss discontinuing the tea. A better studied alternative to recommend to Mrs. Gomez is chamomile tea. Many studies have been conducted that show chamomile is effective in improving sleep quality and reducing anxiety. It has also been shown to decrease blood pressure and inflammation (Sah et al, 2022). 2.) Describe the physical exam and diagnostic tools to be used for Mrs. Gomez. Are there any additional things you would have liked to be included that were not? The first portion of Mrs. Gomez physical examination included reviewing her vital signs. Her vitals are within normal range and as follows: BP: 128/78, HR: 60, RR: 16, Temperature: 98.6F (Williams, 2023). Mrs. Gomez weight was 185lbs which was found to be 10lbs heaver that on her previous visit. Next, her heart, lung, and abdominal sounds were auscultated and found to be normal. She also received a full physical examination that was normal. This included assessing

her cranial nerves, palpating her abdomen, and HEENT (Head, eyes, ear, nose, and throat) exam. It is important to rule out any physical causes of insomnia such as hypothyroidism before exploring other causes. The patient received routine lab work which included a complete metabolic count, complete blood count, and thyroid panels. The patients’ labs were also found to be in normal range. Mrs. Gomez is displaying signs of major depression. Depression could be the cause for her insomnia, weight gain, and anhedonia. There are several tests that can be completed to determine if patients are experiencing signs of depression or suicidal ideations. One tool that can be used on Mrs. Gomez is the Geriatric Depression Screening tool. This is a self-reporting survey that includes fifteen yes/no questions. If the patient scores a five or greater on the tool this can be indicative of depression (American Psychological Association, 2023). Mrs. Gomez scored a nine when she completed the screening tool which indicates depression. Dr. Lee needs to rule out dementia and Parkinson's as causes of Mrs. Gomez’s depression. This can be completed through a “mini-cog” exam. This is a tool that asks a series of questions that test the patient's memory skills. Mrs. Gomez score was normal, and Dr. Lee does not believe that she may be suffering from dementia or Parkinson's disease. One last tool that can be used at all patient visits for quick depression screen is the patient health questionnaire-9 or PHQ-9. This is a series of short yes or no questions that ask patients about their mental health. This is a great tool because it is short and easy and can be given during all wellness or sick visits. Mrs. Gomez was also screened for suicidal ideation. She was asked a series of questions including had she ever thought about going to sleep and not waking up. Mrs. Gomez reports that she has not had any of those thoughts and it is against her religious beliefs. It is important to screen all patients during wellness and sick visits for suicidal thoughts. Dr. Lee also asked the patient about physical or mental abuse from her daughter. He also spoke to her daughter who reported that it was stressful to become the primary caregiver for her mother. Her daughter denies ever physically or mentally abusing the patient. Mrs. Gomez does not have any physical signs of abuse such as bruising and denies verbal abuse. After assessing Mrs. Gomez and her daughter, Dr. Lee ruled out abuse as the cause of depression. I do not think that there were any further tests that should have been conducted. The patient received through physical exam and lab work. She was screened for signs of mental health disorders and suicidal ideations. Mrs. Gomez was also screened for abuse, which is another important part of the psychosocial assessment for all patients. Abuse at home can be a major cause of depression in elderly and non-elderly patient populations. 3.) 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? The first differential diagnosis that was considered was hypothyroidism. Hypothyroidism can cause fatigue, lethargy, personality changes, inability to exercise and weight gain (Dunphy et al, 2019). Hypothyroidism does not typically cause insomnia but hypersomnia. Mrs. Gomez’s

thyroid levels were checked and found to be normal, which ruled out hypothyroidism as a diagnosis. The second diagnosis considered was dementia or Parkinson's diseases. Degenerative disorders such as dementia and Parkinson’s disease are often difficult to diagnosis in the initial stages. They may present with depression, memory loss, and insomnia that is slow and insidious (Dunphy et al, 2019). Patients may also have trouble concentrating. Mrs. Gomez does report that she has not been able to read because she cannot focus on the pages. Mrs. Gomez answered all questions during her assessment appropriately and passed her “MiniCog” exam. This decreased the likelihood that dementia or Parkinson’s disease is the cause of her insomnia. However, due to the slow progression of these diseases, if this is suspected Dr. Lee may need to repeat the “mini-cog” exam on the patient's next visit. The last diagnosis was major depressive disorder. This is the most probable cause of Mrs. Gomez's insomnia. This is also my final diagnosis for Mrs. Gomez. Mrs. Gomez reports that she recently lost her husband of 30 years. She has lost interest in activities that she normally loved like going to church and reading. She also reports difficulty concentrating and has not been able to finish a book. Mrs. Gomez says she has not had the energy to exercise and has been watching television and eating junk food. The recent loss of her husband as well as change in environment and loss of independence could be a trigger for depression. Mrs. Gomez moved in with her daughter, and reports she feels bad that she has not had the energy to contribute around the house. When the Geriatric Depression Screening was completed, it was positive for major depression. After ruling out other physical causes for the patient's insomnia, major depression is likely the cause. 4.) 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’s number one complaint on the visit was insomnia. It is not recommended to prescribe medication as a first line treatment for insomnia (Williams, 2023). Strong medication such as zolpidem (Ambien) can increase the risk of confusion and falls especially in the elderly population. It is also not recommended to use medications that have diphenhydramine (Benadryl)such as the Tylenol PM that the patient tried at home. These can cause anticholinergic side effects in elderly patients including urinary hesitancy, constipation, dry mouth and over sedation (Burchum & Rosenthal, 2021). The best line of defense against insomnia is improving sleep hygiene. This includes developing a bedtime routine, stopping caffeine and alcohol consumption several hours before bed, and reducing screen time thirty minutes before bed (Williams, 2023). Mrs. Gomez might find it helpful to drink a cup of Camille tea and take a warm bath about thirty minutes before bed. She should be provided with education on bath safety as burns are more likely in the elderly population. The most important aspect of treating Mrs. Gomez insomnia is correcting the underlying problem. Mrs. Gomez is suffering from major depression disorder and should be treated appropriately. Dr. Lee wants to start Mrs. Gomez on the selective serotonin reuptake inhibitor

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(SSRI) called sertraline (Zoloft). SSRIs are an excellent choice for elderly patients because they are less likely to cause sedation (Burchum & Rosenthal, 2021). Mrs. Gomez will be prescribed a low dose of sertraline at 25mg daily in the morning. It is better to start low and observe how the patient tolerates the medication and then increase the dose if necessary. “The most common side effects are sexual dysfunction, nausea, headache, and manifestations of CNS stimulation, including nervousness, insomnia and anxiety (Burchum & Rosenthal, 2021, p. 218).” Mrs. Gomez should be instructed to report any of these symptoms to her primary care provider immediately. Dr. Lee also notes that the patient is taking methyldopa for her hypertension. Methyldopa can cause depression and reduced ability to concentrate (Burchum & Rosenthal, 2021). Dr. Lee made the decision to change Mrs. Gomez methyldopa to amlodipine, a different antihypertensive medication. During Mrs. Gomez’s first follow-up appointment she reports that her symptoms are worse and that she has not started taking her medication. Many patients feel as though there is a stigma around mental health, and they may be embarrassed to take the medication. Open ended questions should be asked to the patient to determine if this may be the reason, she did not take the medication. Mrs. Gomez is worried that people will “think she is crazy” and that she should be able to deal with her own emotions without medications (Williams, 2023). Dr. Lee provides education that depression can be caused by chemical imbalances and that it is no different than taking medication for hypertension. Mr. Gomez agrees to try the medication. Dr. Lee also recommends that the patient receive therapy as part of her treatment regimen. One way to incorporate Mrs. Gomez cultural beliefs is to find a therapist that can support her beliefs. She may also find comfort in speaking. with someone at her church who is trusted and can provide support. Exercise has also been proven to improve symptoms of depression (Schuch & Stubbs, 2019). This would also benefit Mrs. Gomez diabetes and may help her reduce her weight. She agrees to try to start walking short distances daily. During Mrs. Gomez’s second follow-up visit she reports she is feeling much better. She sleeps better at night and has even started going back to church. Dr. Lee administers the patients Geriatric Depression Screening, and her score goes from a 9 to 4. This indicates that her depression has improved. Mrs. Gomez reports that she has started exercising daily and is able to walk a little further each day. She reports that she had nausea when she started the medication, but that has now improved. Patients may have nausea when starting an SSRI but should be educated that this often resolves after taking the medication for a few weeks. Mrs. Gomez education during this visit should include reinforcing sleep hygiene as well as following her medication regime. She should be encouraged to return if her symptoms worsen, or she starts having suicidal ideation. Mrs. Gomez should also receive a follow-up appointment in the next 2-3 months to reassess for depression as well as monitor the effectiveness of her new blood pressure medication. References American Psychological Association. (2023). Geriatric Depression Scale. https://www.apa.org/pi/about/publications/caregivers/practicesettings/assessment/tools/geriat ric-depression

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary Care (5th ed.). F. A. Davis Company. Fischbach, F., & Fischbach, M. (2018). Fischbach's A Manual of Laboratory and Diagnostic Tests (10th ed.). Wolters Kluwer Health. Burchum, J., & Rosenthal, L. D. (2021). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants (2nd ed.). Elsevier Health Sciences (US). Mini-Cog.(2023). Quick screening for early dementia detection. https://minicog.com/download- the-mini-cog-instrument/ Sah A, Naseef PP, Kuruniyan MS, Jain GK, Zakir F, Aggarwal G. A Comprehensive Study of Therapeutic Applications of Chamomile. Pharmaceuticals (Basel). 2022 Oct 19;15(10):1284. doi: 10.3390/ph15101284. PMID: 36297396; PMCID: PMC9611340. Schuch, F., Stubbs B. (2019). The Role of Exercise in Preventing and Treating Depression. Current Sports Medicine Reports 18(8):p 299-304, | DOI: 10.1249/JSR.0000000000000620. https://journals.lww.com/acsmcsmr/fulltext/2019/08000/the_role_of_exercise_in_preventing_a nd_treating.6.asp

6001-W4-D5

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