NURS 8250-Discussion Mental Health Apn Week 4

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Discuss the 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.
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?
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?
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?

Apply information from the Aquifer Case Study to answer the following discussion questions:

Discuss the 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.

Chief Complaint: Mrs. Gomez is a 65-year-old woman with trouble sleeping

HPI: Patient with ongoing issue for several years with difficulty sleeping. She now lives with her dght and son in law after her spouse of 30 years has passed away. Patient has gained 10 lbs in the last six months. Patient feels as though she is in slow motion and has stopped attending church and no longer reads which was at one point enjoyable. She feels as though she is unable to focus and will read the same page “over and over.” Patient denies thoughts of suicide or harming oneself.

PMH: Hypercholesterolemia, Type 2 diabetes, Hypertension

Social: Lives with her daughter and son in law since spouse passed away after 30 years of marriage, non-smoker, denies alcohol Discussion Mental Health Apn Week 4

Surgical history: Cholecystectomy, Hysterectomy (due to fibroids)

Medications: Glyburide (10 mg daily) and Metformin (1,000 mg bid) for diabetes, Methyldopa (250 mg bid) and Lisinopril (10 mg daily) for HTN, Atorvastatin (80 mg daily) for hypercholesterolemia, Aspirin 81 mg daily for CHD prohylaxis, Calcium citrate with vitamin D (600mg/400 IU bid) for osteoarthritis prevention, and Diphenhydramine and zapote tea.

Significant labs: Her last hemoglobin A1c has climbed to 8.7%.”

Head, eyes, ears, nose and throat (HEENT): No thyromegaly, adenopathy, or masses.

Pain: Denies

Resp: denies shortness of breath, denies apnea, denies snoring, CTA

Constitutional: denies fevers or dizziness.

Cardiac: Denies chest pains, palpitations, no edema,

Gastrointestinal: Denies nausea, denies changes in bowel habits, hematochezia or melena.

Endocrinologic: No polydipsia or polyuria,

Neurologic: No acute neurologic changes or tremors. AAOx3, no confusion, Cranial nerves 3-12 intact. Normal strength and light touch sensation in extremities. No tremors. Normal gait.

Urologic: Normally urinates one to two times at night, denies difficulty urinating

Vital signs: HR 60 beats/minute and regular, RR 16 breaths/minute, BP 128/78 mm Hg WT: 186 pounds (up 10 pounds since last year), HT 64 in

· 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?

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I would perform a full assessment with a focus on the patient’s current state of mind. I would also like to know how much zapote tea she normally consumes daily. Zapote contain glucoside which decreases blood pressure. In higher doses zapote can act as a sedative and arthritic pain reliever.

· 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?

1. Depression- Geriatric Depression Scale – Short Form (GDS-SF) with Mrs. Gomez. Her score was a 9 so that confirms depression. Major depression affects up to 15% to 20% of people older than 65 years of age (Frank. 2014).

2. Dementia; Mini-Cog exam was given to patient to screen for dementia but she scores in the normal range which rules out dementia.

3. Hypothyroidisim: Over 200 million people worldwide suffer from thyroid issues, which affect women four to seven times more than men. An underactive thyroid can make an individual feel fatigued, apathetic, changes in mood and behavior. Checking the level of thyroid stimulating hormone (TSH) would help make the diagnosis.

· 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?

Medications: Sertraline 25 mg daily will be given to the patient to treat depression. Sertraline is well tolerated and available in a generic form. When treating any patient, it is important to consider the person’s quality of life. The goal of treatment is to maximize their quality of life so they can function, physically and emotionally to their greatest ability (Frank, 2014).

Education: Educating the patient on the side effects of sertraline is also necessary. Potential side effects include headache, nausea, diarrhea, sleepiness, and insomnia, which is less frequent. She will also be instructed to follow through with the medication and to take the regime for at least 9 to 12 months with doses being adjusted accordingly. I would also would to let her know that if she takes the medicine and begins to feel better it is advised to continue with taking the medicine daily to prevent relapse of depression (Frank. 2014). Ms. Gomez will also be instructed to report any confusion, weakness, difficulty concentrating, and memory impairment as this may be a sign of hyponatremia. If this should occur Ms. Gomez will need to have appropriate medical intervention and discontinuation of the SSRI (Canadian Agency for Drugs and Technologies in Health. 2015). Ms Gomez will also be educated on developing a sleep schedule. It would be advised to cut out any caffeine, alcohol, spicy foods, and sugary foods 4-6 hours before bed, limit daytime napping, and avoid exercise or strenuous activity before bedtime. Discussion Mental Health Apn Week 4

Lab work for CBC, BMP, and TSH: to rule out any other disorders.

Psychotherapy would also be beneficial for talk therapy. Ms. Gomez has lost her spouse of not only 30 years but she has had to move in with her adult child. This will cause a significant loss of independence, financial loss, grieving for her spouse, and grieving for the life she once had.

Exercise would be recommended to help enhance mood as well as for the health benefits. The Mayo Clinic (2017) suggests exercise to reduce depression, anxiety and to improve high blood pressure, diabetes and arthritis while improving socialization. To start, 30 minutes per day for three to five days a week may significantly improve depression and anxiety symptoms while smaller amounts of physical activity broken up over the course of the day is beneficial.

Follow up: In two weeks for drug effectiveness with continued follow up visits to ensure drug effectiveness. 8% of people starting selective serotonin reuptake inhibitors (SSRIs) will develop hyponatremia related to syndrome of inappropriate secretion of antidiuretic hormone. This is reversible but should be monitored by checking blood levels 1 month after starting an SSRI. It is recommended that doses be increased regularly and quickly until the maximum cited dose is reached, side effects limit further increases, or good symptom improvement occurs. Checking adherence is important, as patients might not voluntarily report missing doses or side effects. Change in medication should be considered if patients have no response after 4 weeks on the maximum dose or have only partial response after 8 weeks of treatment. 10% to 20% of patients develop chronic depressive symptoms despite treatment and 25% to 30% of patients fail to respond to initial therapy (Frank. 2014).

Canadian Agency for Drugs and Technologies in Health. (2015). Antidepressants in Elderly Patients with Depression and Dementia: A Review of Clinical Effectiveness and Guidelines. Retrieved https://www.cadth.ca/sites/default/files/pdf/htis/aug-2015/RC0689%20-%20Antidepressants%20in%20the%20Elderly%20Final.pdf

Frank C. (2014). Pharmacologic treatment of depression in the elderly. Canadian family physician Medecin de famille canadien, 60(2), 121–126.