6001-W4-D9

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Nursing

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Nov 24, 2024

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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 came into the clinic stating that lately, she has been feeling tired and unable to sleep. She states that for the last six months, she is only able to sleep for a couple of hours before she wakes up. She states that she feels as if she has no energy to do anything, and feels negatively about being unable to help around the house (Hay, n.d.). Mrs. Gomez feels as if she just spends her days eating junk food and watching television. Mrs. Gomez’s daughter states that she moved in with them last year after her father (Mrs. Gomez’s husband) passed away. Mr. and Mrs. Gomez had been married for over 30 years, and Mrs. Gomez endorses that she is sad when she thinks about the past but denies being sad the majority of the time (Hay, n.d.). From the daughter’s point of view, she denies this saying that Mrs. Gomez spends her days moping around the house, saying that it appears she is in slow motion, and has not been participating in previous activities like she used to. Her mother used to attend church multiple times per week, but lately, she has stopped going altogether (Hay, n.d.). She has also stopped reading, which was something she used to enjoy. She endorses that her mother is walking around at night and turning on the TV, which is disturbing the sleep of herself and her spouse. Mrs. Gomez says she stopped reading because it is like she is unable to focus because she just reads the same page repeatedly. She denies suicidal ideations because of religious beliefs. Previous medical history includes hypertension, hypercholesterolemia, and DM type 2. For diabetes, the patient was prescribed glyburide and metformin, for hypertension she was prescribed methyldopa and lisinopril, and for elevated cholesterol she was given Lipitor. Preventative prescription include aspirin and calcium with vitamin D. To address the sleep disturbance, she was taking Tylenol PM but stopped because it was causing her mouth to dry out (Hay, n.d.). The patient has also an herbal tea called flor de tila as a natural remedy for insomnia but stated it was ineffective. Surgical history includes gallbladder removal and a hysterectomy due to fibroids (Hay, n.d.). The patient denies smoking and endorses drinking small amounts on holidays. 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? Major depressive disorder (MDD) is a clinical diagnosis that is based on signs and symptoms reported by the patient; there is no specific diagnostic test for MDD (Bains & Abdijadid, 2023). A complete physical examination should be performed to rule out a physical/medical cause for the depression. In addition, a CBC, CMP, TSH/free T4, vitamin D, urinalysis, and toxicology panel can be performed to rule out a medical explanation (Bains & Abdijadid, 2023). For screening, the Patient Health Questionnaire (PHQ-9), is a standardized scale that can be used to screen, diagnose, and monitor treatment response for depression. The questionnaire directly corresponds with the DSM-5 criteria for depression with a score range of 0 to 27. If a patient scores 10 or more, it can possibly indicate MDD (Bains & Abdijadid, 2023). For Mrs. Gomez, she was asked questions based on the Geriatric Depression Scale (GDS) Please list three differential diagnosis and explain why you chose them. What was your final diagnosis and how did you make that determination? The differential diagnoses for this condition include dementia, depression, and obstructive sleep apnea. Dementia was chosen due to the patient’s age and clinical presentation but ruled out because it does not appear that she has an impaired ability to think, recall, or make choices during daily activities

(Centers for Disease Control and Prevention [CDC], 2019). Obstructive sleep apnea was considered because the patient has associated comorbidities such as obesity, diabetes, and older age but ruled out because excessive daytime sleepiness, loud snoring, and morning headaches are not a part of the patient’s or her daughter’s complaints (Mayo Clinic, 2023). Major depressive disorder was chosen and selected because of the patient’s clinical presentation. She presents with a lack of energy, anhedonia, alteration in appetite or eating habits, and sleep disturbances (Bains & Abdijadid, 2023). What plan of care will Mrs. Gomez be given at this visit, including drug therapy and treatments; what is the patient education and follow-up? For patients who have been diagnosed with depression, it is always important to ask about suicidal ideations (Bains & Abdijadid, 2023). Medication and therapy together are more effective than medication alone. Mrs. Gomez was prescribed sertraline 25mg QD, and was counseled on common side effects of the medication including diarrhea, sleepiness, insomnia (uncommon), headache, and nausea (Hay, n.d.). The patient was informed that she would be started on a moderate dose, and follow up in two weeks to monitor the plan of care and address any concerns. It should be noted that it can take a month to a month and a half for the prescribed medication to be effective. Mrs. Gomez was instructed to complete some lab work, including her A1C to see how well her diabetes has been controlled. The methyldopa may be responsible for exacerbating the depression, so the medication was changed to amlodipine 5mg QD. What was not done during the initial plan of care was addressing the stigma behind mental health treatment. There are many misconceptions behind mental health treatment, including that a person is “crazy” because they need medication. Because Mrs. Gomez was under the same impression, she had not been following the plan of care and her symptoms persisted. The patient’s continued MDD symptoms were beginning to negatively impact other family members, including the patient’s daughter. Once the patient was counseled on mental health treatment, and provided interventions such as going to the local mall to get exercise, both she and her daughter reported an improvement in her symptoms. References Bains, N., & Abdijadid, S. (2023, April 10). Major depressive disorder. ncbi.nlm.nih.gov. Retrieved November 14, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK559078/ Centers for Disease Control and Prevention. (2019, April 5). About dementia. Retrieved November 14, 2023, from https://www.cdc.gov/aging/dementia/index.html#:~:text=Dementia%20is%20not%20a%20specifi c,a %20part%20of%20normal%20aging. Hay, W. (n.d.). Family medicine 03: 65-year-old female with insomnia (M. P. Seagrave, Ed.). southunurs.meduapp.com. Retrieved November 13, 2023, from https://southunur.meduapp.com/document_set_document_relations/30223 Mayo Clinic. (2023, July 14). Obstructive sleep apnea. mayoclinic.org. Retrieved November 14, 2023, from https://www.mayoclinic.org/diseases-conditions/obstructive-sleep-apnea/symptoms

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