I NEED A RESPONSE TO THIS CASE STUDY

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Case 1: Volume 2, Case #16: The woman who liked late-night TV

The patient is a 70-year-old female with chief compliant of “being sad.” The patient is exhibiting signs and symptoms of depression due to increased loneliness. She has a home aide to assist her for her ADL’s as well as her son. She is hard of hearing and has extensive medical issues such as HTN, hypothyroidism, CAD, anemia, allergies, and obesity. Patient has never been on psychotropic medications. She has a family history of depression. Her condition became worse when she was unable to sleep perhaps due to restless leg syndrome (RLS). She has been suffering from daily crying spells. 

1. Do you feel sleepy or do you have occasional sleep attacks during the day? Describe your usual night sleep. (Hours of sleep, frequency of waking up, quality, etc.). Sleep deprivation can lead to depression or worsening depression. Chronic sleep deprivation can lead to depression potentially attributing to neurochemical changes in the brain (Al-Abri, 2015). 
2. Have any of your family members had a history of being depressed? Any mental health issues? History of suicide? Do you have any thoughts of killing yourself? Genetic factors play a huge role in the development of major depressive disorder (MDD) (Lohoff, 2010). 
3. Have you ever suffered from depression, anxiety, or any other mental health issues in the past? Patient’s mother suffered from MDD. Patient reports loneliness. Spouse died. History of traumatic events or history of mother having MDD can cause depression especially now that the patient is lonely. 

The people that would be most closely involved with this patient would be her son and her home aide. Asking them specific questions on how the patient is doing every day. How she performs her ADL’s? What is she describing to them in terms of depression? How is she describing her RLS while she is sleeping? Do they observe her snoring when she sleeps? When does she take “naps?”

An exam to perform would be an actigraphy which is a device that records and measures human rest/activity cycles. It is a small unit that is worn for a week or two and measures gross motor activity, used to assess sleep-wake cycles or circadian rhythms. It is useful for assessing insomnia (Martin & Hakim, 2011).

Another exam to perform would be a polysomnography, also called a sleep study test. It records your brain waves, oxygen in the blood, heart rate, and breathing, as well as eye and leg movements while you sleep. The patient has depression with associated insomnia which a sleepy study can detect a pattern and help treat the insomnia (Hein et al., 2017).

Three Differential Diagnosis: 

1. Major Depressive Disorder (MDD) – a mental health condition which consists of depressed mood that persists for at least 2 weeks duration or longer. Signs and symptoms include poor appetite, insomnia, crying spells, sadness, loss of interest in activities, impairment of daily life, and a combination of biological, psychological, and social sources of distress. MDD is most likely the diagnosis for this patient. 
2. Insomnia – the patient could be having insomnia due to her RLS and the sleeping problem may be the underlying factor towards depression. However, in most cases the patient begins to become depressed and the depression is ultimately what leads to insomnia (Lohoff, 2010). 
3. Persistent depressive disorder – it is unknown when the patient’s depression originated, but the patient must be clinically depressed for over 2 years without remission. 

  Pharmacological methods: 

I would begin treatment with an SSRI such as Celexa 10 mg daily PO and Sonata at 5 mg QHS PO for insomnia. Celexa is a selective serotonin reuptake inhibitor and is classified as an antidepressant. It works by boosting neurotransmitter serotonin, blocks serotonin reuptake pumps, and desensitizes serotonin receptors. (Stahl, 2008). Onset of therapeutic actions typically take up 2-4 weeks and may need to be titrated. Doses of over 20mg/day for elderly patients is not advisable and can cause abnormal changes in electrical activity of the heart in doses over 40 mg/day (Stahl, 2008). Beginning the patient on Sonata which is a non-benzodiazepine hypnotic that binds B selectively to a subtype of the benzodiazepine receptor and May enhance GABA inhibitory actions that provide sedative hypnotic effects more selectively. Inhibitory actions in sleep centers may provide sedative hypnotic effects (Stahl, 2008). Generally, takes about an hour to kick in, and improves quality of sleep. If insomnia does not improve after 7-10 days, the patient needs to be evaluated independently for her RLS and or obstructive sleep apnea. Sonata has a less effect on respiratory depression which would be beneficial for this patient if she does indeed have sleep apnea. Her RLS needs to be evaluated by medical physician and can help her sleep and reduce depression.

Lessons Learned: 

                Geriatric depression can be complicated given all the psychosocial issues that can be involved, as well as comorbidities such as in this case. Side effects become a burden with the elderly population and must be monitored throughout treatment. In this case study, a medical doctor as well as a psychiatrist is needed and possibly different interdisciplinary members. The patient is involved in home health as well which would need to be revisited with the addition of psychotropic medications.

References 

Al-Abri M. A. (2015). Sleep Deprivation and Depression: A bi-directional association. Sultan Qaboos University medical journal, 15(1), e4–e6.

Hein, M., Lanquart, J. P., Loas, G., Hubain, P., & Linkowski, P. (2017). Similar polysomnographic pattern in primary insomnia and major depression with objective insomnia: a sign of common pathophysiology?. BMC psychiatry, 17(1), 273. https://doi.org/10.1186/s12888-017-1438-4

Lohoff F. W. (2010). Overview of the genetics of major depressive disorder. Current psychiatry reports, 12(6), 539–546. https://doi.org/10.1007/s11920-010-0150-6

Martin, J. L., & Hakim, A. D. (2011). Wrist actigraphy. Chest, 139(6), 1514–1527. https://doi.org/10.1378/chest.10-1872

Stahl, S. M. (2008). Essential Psychopharmacology Online. Retrieved from: https://stahlonline-cambridge-org.ezp.waldenulibrary.org/prescribers_drug.jsf?page=9781316618134c24.html.therapeutics&name=Citalopram&title=Therapeutics

Assignment Details

Diabetes Case Study

Chief Complaint

“My left foot feels weak and numb. I have a hard time pointing my toes up.”

History of Present Illness

D.T. is 42-year-old Caucasian woman who has had an elevated blood sugar and cholesterol 2 years ago but did not follow up with a clinical diagnostic work-up. She had participated in the state’s annual health screening program and noticed her fasting blood sugar was 160 and her cholesterol was 250. However, she felt “perfectly fine at the time” and did not want to take any more medications. Except for a number of “female infections,” she has felt fine recently.

Today, she presents to the clinic complaining that her left foot has been weak and numb for nearly 3 weeks and that the foot is difficult to flex. She denies any other weakness or numbness at this time. She does report that she has been very thirsty lately and gets up more often at night to urinate. She has attributed these symptoms to the extremely warm weather and drinking more water to keep hydrated. She has gained a total of 50 pounds since her last pregnancy 10 years ago, 20 pounds in the last 6 months alone.

Past Medical History

• Seasonal allergic rhinitis (since her early 20s)
• Breast biopsy positive for fibroadenoma at age 30
• Gestational diabetes with second child 10 years ago
• Multiple yeast infections during the past 3 years that she has self-treated with OTC antifungal creams and salt bath
• Hypertension for 10 years

Past Surgical History

C-section 14 years ago

OB-GYN History

• Menarche at age 11
• Last pap smear 3 years ago

Family History

• Type 2 DM present in older brother and maternal grandfather. Both were diagnosed in their late 40s. Brother takes both pills and shots.
• Mother alive and well
• Father has COPD
• Two other siblings alive and well
• All three children are alive and well

Social History

• Married 29 years with 3 children; husband is a school teacher
• Family lives in a four bedroom single family home
• Patient works as a seamstress
• Smokes 1 pack per day (since age 16) and drinks two alcoholic drinks 4 days per week
• Denies illegal drug uses
• Never exercises and has tried multiple fad diets for weight loss with little success. She now eats a diet rich in fats and refined sugars.

Allergies

NKDA

Medications

• Lisinopril 10 mg daily
• Loratadine 10 mg daily

Review of Systems

General

Admits to recent onset of fatigue

HEENT

Has awakened on several occasions with blurred vision and dizziness or lightheadedness upon standing: Denies vertigo, head trauma, ear pain, difficulty swallowing or speaking

Cardiac

Denies chest pain, palpitations, and difficulty breathing while lying down

Lungs

Denies cough, shortness of breath, and wheezing

GI

Denies nausea, vomiting, abdominal bloating or pain, diarrhea, or food intolerance, but admits occasional episodes of constipation

GU

Has experienced increased frequency and volumes of urination, but denies pain during urination, blood in the urine, or urinary incontinence

EXT

Denies leg cramps or swelling in the ankles and feet; has never experienced weakness, tingling or numbness in arms or legs prior to this episode

Neuro

Has never had a seizure and denies recent headaches

Derm

Has a rash under her bilateral breast and in groin area

Endocrine

Denies a history of goiter and has not experienced heat or cold intolerance

Vital Signs

BP 165/100, T 98 F, P 88 regular, HT 5 feet 4 inches, RR 20 non labored, WT 210 lbs

What you need to do:

• Develop an evidence-based management plan.
• Include any pertinent diagnostics.
• Describe the patient education plan.
• Include cultural and lifespan considerations.
• Provide information on health promotion or health care maintenance needs.
• Describe the follow-up and referral for this patient.
• Prepare a 3–5-page paper (not including the title page or reference page).

Format

The paper should be no more than 3–5 pages (not including the title page and reference pages.

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