Week 4 Discussion Discussion Mental Health

Sample Answer

The Mrs. Gomez’s History

This discussion focuses on Mrs. Gomez’s history which is relevant to her insomnia. It includes chief complaint, HPI, social, family, and past medical history that are essential to know.

Patient Initials MG

Subjective Data MG presents with an ongoing problem of feeling extremely tired and inability to sleep properly for the past six months. The patient is in grief following the recent death of her husband. She reports fatigue, weight gain, and loss of interest in activities she once enjoyed such as going to church and reading. She says that she has lost focus and can read the same page continuously. She denies suicide ideation or self-injury.

Chief Complaint A 65-year-old Mrs. Gomez claims to be extremely tired lately and has trouble sleeping. HPI The patient presents with complaints of insomnia for the last six months. She says that she only manages to sleep for a few hours every night.

• Onset Six months ago
• Location General
• Duration She reports sleeping a few hours every night
• Characteristics Loss of focus, extremely tired
• Aggravating factors Watching TV at night
• Relieving Factors None

Treatment MG is on Tylenol PM and Zapote Blanco, a Mexican herbal tea
Severity Rigorous alteration in sleep pattern, which compromises her routine functioning.

PMH Type 2 diabetes, Hypertension, Hypercholesterolemia Social MG is staying with her daughter and son-in-law following the death of her husband of 30 years. She denies smoking and taking alcohol.

Surgical history MG has undergone Cholecystectomy, Hysterectomy
Medications MG has been placed on Glyburide 10 mg daily and Metformin 1,000 mg bid for the management of diabetes, Methyldopa 250 mg bid and Lisinopril 10 mg daily for the management of HTN, Atorvastatin 80 mg daily for the management of hypercholesterolemia, Aspirin 81 mg daily for the management of CHD prophylaxis, and Calcium citrate with vitamin D 600mg/400 IU bid for prevention of osteoarthritis prevention. MG also uses zapote tea and Diphenhydramine.

Pain None

Respiration No apnea, shortness of breath, CTA, snoring
Head, eyes, ears, nose, and throat (HEENT) Denies adenopathy, thyromegaly, or masses

• Cardiac No chest pains, edema, palpitations
• Constitutional No fevers or dizziness
• Significant labs MG’s final hemoglobin A1c has elevated to 8.7%
• Endocrinologic Denies polydipsia or polyuria
• Gastrointestinal No nausea, hematochezia, alterations in bowel habits,
• Neurologic Normal gait, no serious neurologic changes, no confusion, no tremors
  Urologic MG usually urinates once or twice at night without any difficulty
• Vital signs BP 128/78 mm Hg, HT 64 in, WT 186 pounds, HR 60 beats/minute, and regular
  

The Physical Exam, Diagnostic Tools, and Recommended Additional Information
MG’s hemoglobin A1c elevated to 8.7%, which is an indication of uncontrolled blood glucose. It is recommended to conduct laboratory tests such as thyroid stimulating hormone (TSH), complete blood count (CBC), and complete metabolic panel (CMP). These tests are crucial in ruling out other potential causes of insomnia, depression, and fatigue.

They will assess conditions such as vitamin deficiencies, electrolyte imbalance, anemia, and renal or hepatic problems. The additional information I would seek from this patient is the amount of Zapote tea she consumes daily. This tea contains glucoside which reduces blood pressure. It can also act as an arthritic pain reliever and sedative when consumed in higher doses.

Differential Diagnoses for Mrs. Gomez

The first differential diagnosis is hypothyroidism. The majority of people globally are affected by thyroid problems, which disproportionally affect women compared to men. Hypothyroidism can make a person feel fatigued, alter mood and behavior, and feel apathetic (Wilson et al., 2021).

The second differential diagnosis is dementia. However, this diagnosis was ruled out after MG scored normal range in the Mini-Cog exam. The final diagnosis was depression. An episode of depression entails at least five symptoms such as depressed mood, unintended changes in weight, impaired concentration, recurrent suicide ideation, significant changes in sleep pattern, and feeling worthless (Paykel, 2022). MG presents at least five of the symptoms that confirm depression.

Plan of Care for Mrs. Gomez at Visit, Patient Education, and Follow-up
The main treatment plan of choice for MG includes diet, Sertraline, cognitive-behavioral therapy (CBT), and exercise. MG should be placed on sertraline to manage depression. This medication is well-tolerated and accessible in a generic form (Guerrera et al., 2020). The goal of treatment is to optimize the quality of life of MG to enable her to function emotionally and physically to the best of their ability.

CBT is crucial for MG to help her cope with the loss of a spouse and move on with life. Exercise is critical in helping to improve mood and other health benefits such as improving diabetes and blood pressure.

Mrs. Gomez should be educated on the possible side effects of sertraline. Education should also cover the need to adhere to the medication’s proper dosage even after starting to feel better (Guerrera et al., 2020). She should be advised to report any problem or side effects she encounters during the treatment process.

Mrs. Gomez should also be advised to create a sleep schedule. She should be discouraged from using certain drinks such as alcohol, sugary foods, and caffeine a few hours before going to bed. On the other hand, follow-up is necessary to determine the effectiveness of the medication (Schramm et al., 2019). Follow-up is also crucial in monitoring medication compliance since some patients do not report side effects or missing doses.

References

• Guerrera, C. S., Furneri, G., Grasso, M., Caruso, G., Castellano, S., Drago, F., … & Caraci, F. (2020). Antidepressant drugs and physical activity a possible synergism in the treatment of major depression? Frontiers in Psychology, 11, 857. https //doi.org/10.3389/fpsyg.2020.00857
  
• Paykel, E. S. (2022). Basic concepts of depression. Dialogues in clinical neuroscience. https //doi.org/10.31887/DCNS.2008.10.3/espaykel
  
• Schramm, E., Kriston, L., Elsaesser, M., Fangmeier, T., Meister, R., Bausch, P., … & Härter, M. (2019). Two-year follow-up after treatment with the cognitive behavioral analysis system of psychotherapy versus supportive psychotherapy for early-onset chronic depression. Psychotherapy and psychosomatics, 88(3), 154-164. https //doi.org/10.1159/000500189
  
• Wilson, S. A., Stem, L. A., & Bruehlman, R. D. (2021). Hypothyroidism diagnosis and treatment. American family physician, 103(10), 605-613. https //pubmed.ncbi.nlm.nih.gov/33983002/