Week 4 Advance Practice comment
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 sixty-five-year-old female with the chief complaint of “can’t seem to sleep”. She reports to the healthcare provider that for the past six months, sleep has only occurred in 2-3-hour increments, each night. According to her daughter, she no longer attends church or reads, which was once her favorite hobbies. The patient admits to feeling guilty for the change in her behavior and mood and for no longer helping her daughter with housework. Mrs. Gomez states “I don’t have the energy to do anything”. Lack of concentration has also become a problem for the patient, and she attributes this problem to the reason she no longer reads. Her appetite has changed in that she mostly eats unhealthy foods now, while watching television. Sylvia, her daughter states that it seems that her mother is moving in “slow motion”. Lastly, the patient admits to feeling sad but states that she would never be able to harm herself due to religious reasons.
Mrs. Gomez’s husband of thirty-years passed away last year, and she has since relocated to her daughter’s home. She denies a history of smoking but admits to having alcoholic beverages recreationally. Past medical history includes hypertension, hypercholesterolemia, and diabetes. Home medications include Glyburide 10mg per day, Metformin 1000mg BID, Methyldopa 250mg BID, Lisinopril 10mg per day, Atorvastatin 80mg per day, Aspirin 81 mg daily, and Calcium citrate with Vitamin D 600mg/400 IU BID. The patient also admits to using Diphenhydramine and zapote tea.
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 SIG E CAPS mnemonic was used to assess Mrs. Gomez for depression and the results are expressed above. Also, the Geriatric Depression Scale aided the health care providers in making a diagnosis, and the Mini-Cog examination helped rule out other conditions. A CBC, CMP and TSH were collected on Mrs. Gomez to evaluate for electrolyte abnormalities, anemia or other illnesses that could be causing her mood changes. TSH evaluation should always be considered due to the link between hypothyroidism and depression, as well as, other cognitive impairments (Tayde et al., 2017). On assessment, the patient’s vital signs are within normal range, and the physical examination is unremarkable. With a ten-pound increase in weight from last year and the report of fatigue and sadness, as a practitioner, focus should also be placed on the patient’s skin and hair. Is the patient’s skin dry or does her hair appear to be brittle? Is there edema noted in the hands or eyelids (Buttaro et al., 2017).
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?
Hypothyroidism E03.9: This condition is common among women, especially those of older age. Symptoms often present in this group as tiredness and cognitive delay (Ingoe et al., 2018). The objective finding of weight gain and subjective criteria of loss of focus, decrease in enjoyment, and tiredness provides suspicion for this ailment. Acquiring a TSH level in imperative.
Bereavement Z63.4: The patient recently experienced the loss of her husband of thirty years. Her life has been turned upside-down, so to speak, by no longer having her life-long partner and having to move from her home. When older adults experience the loss of a spouse, it is often difficult for him or her to manage everyday life as they once had. This often leads to depression (Bratt et al., 2017).
Dementia F03.90: This diagnosis should be considered due to patient’s age and the report of inability to focus and the observation of moving in “slow motion” by family members.
Depression F32.9: Mrs. Gomez admits to feeling a sense of sadness, especially within the last six months. Having to move in with her daughter has taken away some of her independence. She reports inability to remain asleep at night, lack of energy, failure to focus, loss of interest in hobbies and lack of exercise. Due to the patient presentation, Geriatric Depression Score of 9, and positive response to mood stabilizer (once compliant), the final diagnosis of depression is made.
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 should be encouraged to begin a light exercise regimen as this has been proven to be one of the most valuable tools in reducing depression in older adults (Ahmed, 2019). The patient admitted to mostly eating “junk food”, therefore she should be instructed on the value of incorporating fruits and vegetables into her daily diet. Not only will this assist in maintaining her comorbidities, but it will also build energy levels. Mrs. Gomez is prescribed Zoloft 25mg daily, and Methyldopa is substituted for Amlodipine 5mg daily.
The patient is also encouraged to seek help from a specialized therapist. She should be reassured that this therapy can be used in conjunction with religious practices, such as time with her priest and praying, as this is important to her. Medication education should be provided. Related to Zoloft, the patient should be monitored for feelings of suicide, worsening depression, and cognitive and/or behavior changes (Epocrates, 2019). She should also be made aware that symptoms may not improve for 4-8 weeks, but medication compliance is necessary. Abruptly discontinuing medication can lead to harmful or life-threatening effects and should be avoided. Since the patient is changing blood pressure medications, she should keep a log of measurements to ensure therapeutic response. Make the patient aware that this medication may lead to nausea, flushing or palpitations (Epocrates, 2019).
The patient should be provided access to community resources that relate to her current situation. Bereavement or depression groups are typically available for those in need. Mrs. Gomez should be informed to seek immediate medical attention if she experiences feelings of suicide or develops chest pain, hypotension, hypertension or yellowing of skin.
Discussion #2
Mrs. Gomez is 65yo F complaining of tiredness and inability to sleep for the past six months. Pt has past medical history of HLD, HTN, DM, cholecystectomy, and hysterectomy due to fibroids. Pt takes Glyburide 10mg/daily, Metformin 1gm bid, methyldopa 250mg bid, Lisinopril 10mg/day, Atorvastatin 80mg/day, ASA 81mg/day, and Calcium citrate w/vitamin D 600mg/400 IU bid. Pt states she also takes Tylenol PM and drinks zapote blanco tea. Pt denies pain, breathing issues, smoking and drinks alcohol in small amounts on holidays. Pt states her husband passed away last year and has moved in with her daughter. She states she is sad about her husband and she misses him, but is not sad most of the time. She has stopped participating in activities that she found enjoyable; such as reading and going to church, and that she feels like she is in slow motion and has trouble focusing. She states she spends most of her time watching TV and eating junk food, and that she has gained 10 pounds over the last six months. She states she voids one to two times a night.
During physical exam I would check her thyroid, HEENT, listen to heart and lung sounds, palpate her abdomen and listen for BS, check pulses, and assess neurologic status; including strength, tremors, and gait. I would ask Mrs. Gomez about her sleep habits, appetite, daily activities, energy, concentration, and assess suicide thoughts using SIG E CAPS. Additionally, I would utilize the GDS-SF in assessing her level of depression. According to the scale a score >5 confirms depression; Mrs. Gomez scores a 9. A Mini-cog exam would also be performed – in which case Mrs. Gomez is negative for dementia. I would have a CMP, CBC, TSH, Iron, and B12 labs.
The first diagnosis I would consider is depression F33.2 (endogenous without psychotic symptoms). Mrs. G has signs and symptoms of depression; including the loss of her husband, no interest in previously enjoyed activities, and eating junk food and watching TV. My second diagnosis would be inadequate sleep hygiene Z72.821 (bad or irregular sleep habits, unhealthy sleep wake cycle). Mrs. G is up several times a night to urinate, and she may be watching television just before bedtime. My third diagnosis would be other fatigue R53.83 (exhaustion and fatigue due to depressive episode) (ICD10Data, 2019). The combination of depression and lack of good sleep could contribute to her lack of energy. My final diagnosis would be depression due to the positive scores within her SIG E CAPS and GDS-SF tests, the loss of her husband, having to move-in with her daughter (which is a loss of independence in a way), and the inability to sleep well which would contribute to loss of motivation to do things she enjoys.
My plan of care would be to have her stop the methyldopa which can exacerbate her depression (RxList, 2017), and instead add amlodipine 5mg tablet PO qday for blood pressure control. She will start Sertraline 25mg tablet PO qday for depression. She will be educate that she cannot just stop this medication and that it may cause headaches, drowsiness, nausea/vomiting, and hyponatremia. She will educated that there are many people who suffer from depression and the plan of care is intended to help her get through her tough time and that taking an antidepressant doesn’t mean that she is crazy or weak, and it doesn’t mean she has to be on them for the rest of her life. She will be advised to not drink the zapote blanco tea since it has diuretic properties and causes hypotension; that it may affect the medications she is prescribed. She will be educated that the Sertraline should help with the insomnia. She will be advised to see a grief counselor and to begin light exercise. Mrs. G will be asked to follow up in office in four weeks to re-assess her depression scale and to have labs drawn; including CMP, CBC, and Hgb A1C.
Mura, (2013) found that exercise improved quality of life in depressed patients…the higher the amount of physical activity the larger the improvement in mentation. White sapote (zapote blanco) has hypotensive, diuretic, and sedative properties (Orwa, 2009).
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