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. Patient normally sees 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
By Day 3 of Week 7
Post a response to each of the following: Introduction + references pages
• 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.
Not explain altogether. Write each question with its answer individually.
using formal APA writing convention, using the 7th Edition
References at least 5 and not more than 5 years ago
Sample Solution
When assessing a patient presenting with insomnia, it is important to take into account all possible factors that may be contributing to their symptoms. In this case, the patient’s history of depression and her husband’s passing could be potential contributors which must first be addressed.
If this were my office, three questions I might ask the patient include: Does your insomnia typically occur at night or do you experience difficulty falling asleep during the day as well? Can you tell me any specific stressful events or life changes that have taken place within the past few months? Do you feel like there are any particular emotions underlying your inability to sleep?
The reasoning for asking these questions is twofold. First, determining whether the issue is more of a circadian rhythm disorder or an emotional one can help provide insight on how best to approach treatment. Second, uncovering recent stressful events helps paint a better picture of what other lifestyle modifications may need to be made in order for them cope better with their condition (Liu et al., 2020).
In addition to speaking with the primary caregiver, it would also be beneficial to get feedback from people close to them such partner or family members who may have noticed any behavioral changes since her husband’s passing. Specific questions that can asked here include: How has she been doing since his death? Has she been sleeping more/less than usual lately? Are there any activities they used enjoy together before he passed away which they no longer do now ? The purpose of seeking answers these types inquiries is so we can gain further insight into how bereavement might affect her daily routines and if disrupted sleep patterns are normal part grief process (Chen & Yeh 2020).
