For this Discussion, review the case Learning Resources and the case study excerpt presented. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs.
Case: An elderly widow who just lost her spouse.
Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patients normally see PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications:
• Metformin 500mg BID
• Januvia 100mg daily
• Losartan 100mg daily
• HCTZ 25mg daily
• Sertraline 100mg daily
Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP: 132/86
Post a response to each of the following:
• List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
• Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
• Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
• List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
• List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
• For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?
• Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.
2 Pages only.
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Three questions I might ask the patient if she were in my office are:
Can you tell me more about your sleep habits since your husband’s passing? How long have you been experiencing insomnia and how often does it occur?
How has your mood been since your husband’s passing? Have you noticed any changes in your appetite or energy levels?
Have you been engaging in any activities or hobbies since your husband’s passing? How do you spend your days?
I would ask these questions to gain a better understanding of the patient’s sleep habits, mood, and activities since her husband’s passing. The patient’s insomnia and depression may be related to her grief, and understanding the specific symptoms and duration of her insomnia can help me to determine the best course of treatment. Additionally, understanding her mood and activities can help me to identify any potential triggers or coping mechanisms that may be contributing to her symptoms.
People in the patient’s life I would need to speak to or get feedback from to further assess the patient’s situation include:
Family members or friends who have been in close contact with the patient since her husband’s passing
The patient’s primary care physician
The patient’s husband’s primary care physician
I would ask these people questions such as:
Can you describe how the patient has been coping with her husband’s passing?
Have you noticed any changes in the patient’s mood, sleep, or appetite?
Has the patient been engaging in any activities or hobbies since her husband’s passing?
Has the patient had any other health concerns or changes in her medication regimen since her husband’s passing?
I would ask these questions to gather more information about the patient’s symptoms and how they have changed since her husband’s passing. Additionally, by speaking with the patient’s primary care physician, I can get more information about her medical history and any other health concerns that may be contributing to her symptoms.
Physical exams and diagnostic tests that would be appropriate for the patient include:
A thorough physical examination to assess for any physical symptoms that may be contributing to her insomnia, such as pain or discomfort
A depression screening tool, such as the Patient Health Questionnaire (PHQ-9), to assess the severity of her depression
A sleep diary to track the patient’s sleep habits over time
The results of these tests can be used to identify any physical symptoms that may be contributing to the patient’s insomnia and to determine the severity of her depression. The sleep diary can be used to track the patient’s progress over time and to determine if her insomnia is improving.
A differential diagnosis for the patient includes:
Bereavement-related depression
Insomnia secondary to depression
Insomnia secondary to medication side effects
Chronic pain
The most likely diagnosis for this patient is bereavement-related depression. Her husband’s passing was 10 months ago, and her depression symptoms started after that. The patient’s insomnia may be secondary to her depression, as depression is a common cause of insomnia. The other diagnoses are possible but the patient’s presentation and history point more towards bereavement-related depression.
Two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy are:
Escitalopram 10mg daily
Venlafaxine XR 75mg daily
Escitalopram is a selective serotonin reuptake inhibitor (SSRI) that is commonly used to treat depression. It has a relatively low risk of side effects and is well-tolerated. Venlafaxine XR is a serotonin-norepinephrine reuptake inhibitor (SNRI) that
