6001-W4-D6

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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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Insomnia Mrs. Gomez presents with a chief complaint of persistent insomnia over the last six months, reporting an inability to sleep for more than a couple of hours before waking up. Her daughter, Silvia, provides additional context, mentioning Mrs. Gomez's restless behavior during the night, including walking around and turning on the television, which disrupts the household's sleep. This disrupted sleep pattern is a key concern that needs exploration. Chief Complaint and History of Present Illness (HPI) Mrs. Gomez's chief complaint is fatigue due to inability to sleep for more than a couple of hours over the past six months. The history of interrupted sleep and restless behavior should be thoroughly explored to understand its impact on her overall well-being. Social and Family History Mrs. Gomez's recent move to live with her daughter and the loss of her husband are significant stressors. Understanding the family dynamics, especially the impact of her disrupted sleep on the household, is crucial for a comprehensive assessment. Silvia's observations provide valuable insights into Mrs. Gomez's nighttime behavior. Psychosocial History Mrs. Gomez expresses sadness related to her husband's passing but denies feeling sad most of the time. Silvia, however, highlights her mother's lethargy, reduced engagement in activities like attending church and reading, and a perceived lack of energy. Mrs. Gomez herself acknowledges difficulty focusing and low energy levels. Past Medical History and Medications Chronic conditions such as hypercholesterolemia, type 2 diabetes, and hypertension are identified. Surgical history includes cholecystectomy and hysterectomy due to fibroids. Mrs. Gomez is on a combination of medications, including glyburide, metformin, methyldopa, lisinopril, atorvastatin, aspirin, and calcium citrate with vitamin D. Importantly, she has tried over-the-counter medications like Tylenol PM and herbal tea (Flor de Tila) for sleep without success, indicating a need for a more tailored approach. Social History Mrs. Gomez does not smoke, consumes small amounts of alcohol on holidays, and has no significant substance use history. Mrs. Gomez's difficulty sleeping is multifaceted, involving grief, lifestyle changes, and potential psychological factors contributing to insomnia. Understanding the impact on her daily life, family relationships, and exploring her psychosocial well-being will be vital for a comprehensive assessment and formulation of an appropriate treatment plan (Abad & Guilleminault, 2018, p. 807).

Physical Exam and Diagnostic Tools for Mrs. Gomez Mrs. Gomez's recent examination revealed stable vital signs, including normal temperature, pulse, respiratory rate, and blood pressure, with a noticeable weight gain of ten pounds over the past year. The head, eyes, ears, nose, and throat (HEENT) examination indicated no abnormalities, thyromegaly, adenopathy, or masses. The cardiac assessment demonstrated a regular heart rate and rhythm, without murmurs or gallops, and no signs of edema were observed. Respiratory auscultation detected clear breath sounds, suggesting no respiratory issues. Abdominal examination revealed softness, non- tenderness, and the absence of organomegaly or masses. A comprehensive neurologic examination, including cranial nerves, strength, light touch sensation, absence of tremors, and normal gait, indicated no overt neurological abnormalities. A thorough physical examination is important to help diagnose and rule out certain diagnoses (Dunphy et al., 2019, p. 49). In addressing Mrs. Gomez's mental health status, a delicate inquiry into thoughts of dying or causing harm revealed her hardship and a desire to reunite with her late husband, coupled with a commitment to not harm herself due to religious beliefs. Despite the thorough physical exam, the significant weight gain over the past year, considering Mrs. Gomez's history of chronic conditions, should be explored for its potential impact on her overall health and sleep quality. Additionally, incorporating tools such as a sleep diary could provide more nuanced insights into Mrs. Gomez's sleep patterns and behaviors (Abad & Guilleminault, 2018, p. 807). Differential Diagnoses for Mrs. Gomez 1. Major Depressive Disorder (MDD): Mrs. Gomez's reported symptoms of persistent sadness, reduced energy, diminished interest in activities, and cognitive difficulties, including the inability to focus and decreased motivation, align with the criteria for Major Depressive Disorder (Obuobi-Donkor et al., 2021, p. 2). The recent loss of her husband, along with the substantial life changes, may contribute to the development of depressive symptoms. 2. Hypothyroidism: Given Mrs. Gomez's complaints of fatigue, cognitive difficulties, and a sense of sluggishness, hypothyroidism could be considered as a potential differential diagnosis. Thyroid dysfunction can manifest with depressive symptoms, including cognitive impairment and fatigue, and it is crucial to evaluate Mrs. Gomez's thyroid function through thyroidstimulating hormone (TSH) testing ("Hypothyroidism (underactive thyroid) - Symptoms and causes," 2022). 3. Chronic Fatigue Syndrome (CFS): Chronic Fatigue Syndrome is characterized by persistent fatigue that is not alleviated by rest and is often accompanied by cognitive impairment, muscle pain, and a decreased ability to engage in usual activities. Mrs. Gomez's profound fatigue, lack of energy, and the significant impact on her daily functioning warrant consideration of CFS ("Symptoms of ME/CFS," 2021). Final Diagnosis and Determination Considering Mrs. Gomez's constellation of symptoms, including the cognitive, emotional, and physical aspects, a provisional diagnosis of Major Depressive Disorder is made. This determination is based on the alignment of her reported symptoms with the diagnostic criteria for depression, the contextual stressors such as her husband's recent death, and the potential impact on her independence. However, it is imperative to conduct further investigations, including laboratory tests

like TSH, to rule out medical conditions contributing to her symptoms. The comprehensive evaluation will guide a conclusive diagnosis and inform an appropriate treatment plan tailored to Mrs. Gomez's specific needs Plan of Care for Mrs. Gomez In addressing Mrs. Gomez's symptoms of depression and insomnia, a comprehensive plan of care will involve a combination of pharmacotherapy, psychotherapy, and supportive interventions. 1. Pharmacotherapy: Considering the severity of Mrs. Gomez's depressive symptoms, initiating treatment with a selective serotonin reuptake inhibitor (SSRI) is recommended. SSRIs, such as sertraline, have demonstrated efficacy in the elderly population and are considered a first-line pharmacological intervention for depression (Dudas et al., 2018, p. 6). The initial dosage should be carefully titrated based on Mrs. Gomez's clinical response and potential side effects. 2. Psychotherapy: Concurrently, psychotherapeutic interventions, particularly cognitivebehavioral therapy (CBT), should be incorporated into the treatment plan. CBT has proven effectiveness in addressing depression, enhancing coping mechanisms, and assisting individuals in adapting to life changes ("Depression in adults: Treatment and management," 2022). Engaging Mrs. Gomez in regular psychotherapeutic sessions will provide a supportive environment for expression and exploration of her emotions. 3. Patient Education: Patient education is a vital component of the plan. Mrs. Gomez and her daughter should be informed about the nature of depression, the expected benefits and potential side effects of medications, and the role of psychotherapy in managing her condition. Emphasizing the importance of medication adherence and regular follow-up appointments is crucial for optimizing treatment outcomes. 4. Follow-Up: A structured follow-up schedule should be established to monitor Mrs. Gomez's progress and adjust the treatment plan as needed. Initially, follow-up appointments may be scheduled more frequently to closely monitor treatment response and manage any emerging side effects. As her symptoms improve, follow-up intervals can be extended Additional Supportive Measures: Given the recent stressful life changes, support groups or community resources may be explored to provide Mrs. Gomez with additional emotional support and a sense of connection. Encouraging engagement in activities she previously enjoyed, such as attending church or reading, can contribute to her overall well-being. Physical activity such as exercising daily is necessary to alleviate depressive symptoms. Avoid exercising close to bedtime is equally important to avoid any stimulation to prevent sleep (Abad & Guilleminault, 2018, p. 809). In summary, the plan of care for Mrs. Gomez encompasses a holistic approach, integrating pharmacotherapy, psychotherapy, patient education, and ongoing support. The collaborative efforts of healthcare providers, Mrs. Gomez, and her family will contribute to a more comprehensive and effective management of her depression. References Abad, V. C., & Guilleminault, C. (2018). Insomnia in elderly patients: Recommendations for pharmacological management. Drugs & Aging, 35(9), 791-817. https://doi.org/10.1007/s40266- 018- 0569-8

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Depression in adults: Treatment and management. (2022, June 29). NICE | The National Institute for Health and Care Excellence. https://www.nice.org.uk/guidance/ng222/chapter/Recommendations#treatment-for-anew-episode-of- less-severe-depression Dudas, R., Malouf, R., McCleery, J., & Dening, T. (2018). Antidepressants for treating depression in dementia. Cochrane Database of Systematic Reviews, 2018(8), 1- 75. https://doi.org/10.1002/14651858.cd003944.pub2 Dunphy, Lynne, M. et al. Primary Care. Available from: South University, (5th Edition). F. A. Davis Company, 2019. Hypothyroidism (underactive thyroid) - Symptoms and causes. (2022, December 10). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/hypothyroidism/symptoms- causes/syc20350284 Obuobi-Donkor, G., Nkire, N., & Agyapong, V. I. (2021). Prevalence of major depressive disorder and correlates of thoughts of death, suicidal behaviour, and death by suicide in the geriatric population —A general review of literature. Behavioral Sciences, 11(11), 19. https://doi.org/10.3390/bs11110142 Symptoms of ME/CFS. (2021, February 9). Centers for Disease Control and Prevention. https://www.cdc.gov/me-cfs/symptoms-diagnosis/symptoms.html

6001-W4-D6

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