Week 7 _ Discussion_Treatment for a Patient With a Common Condition

Instructions:

Respond to your colleague in one of the following ways:

· If your colleague’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.

· If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective

**minimum of three (3) scholarly references are required for each reply cited within the body of the reply & at the end**

Reply # 2

Cindy Clermont 

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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 died 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 

The three questions that I would ask my patient and the rationales behind my questions are:

1. I would extend my condolences and ask her; when was the last time she has had a good night’s sleep and what nonpharmacological regimen are you doing to assist?

2. Do you have family? Do you have a family history of depression?

3. I would ask about her PMH, specifically, confirming what diagnoses do you have, when were you diagnosed, when was the last time you took your medications and when were seen for a follow up?

I would ask these questions specifically to better care for the patient. It is imperative to understand the psyche of the patient more so regarding the death of her spouse of 41 years. The patient does have a history of DM, MDD, and HTN. With the death of her spouse, her stress and anxiety level due to grieving can increase as well as her glucose levels, insomnia, blood pressure etc. It is crucial for the safety of the patient and the safety of all people involved that these questions concerns be addressed. Major depressive disorder (MDD) is when symptoms are present during a two-week period and representing a clinically substantial change from previous functioning such as, depressed or irritable mood for most of the day, diminished interest in previously pleasurable activities, significant unintentional weight loss or weight gain, insomnia or hypersomnia, sluggishness, lethargy, feelings of worthlessness or excessive guilt, etc. (Oyama & Piotrowski, 2021).

· 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.

I would need to address why the patient arrived at the clinic by private vehicle. I would like to know if she has family or friends. I would question her living arrangements, lifestyle, and socioeconomics. I'd inquire about her support network—does she have friends/family to talk to? I would ask about her sleeping habits. What does she do for the day? Does she seem tired? Does she nap during the day? What is her bedtime routine?

· Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used. 

I would do comprehensive health assessment and focus on the chief complaint. I would check the glucose level at this time, and still have labs drawn to rule out other possible issues. To determine if her glucose is under control, I would schedule an HGBA1C test. I would look into the patient's use of HCTZ, as it's possible that it's causing her to urinate more frequently, which could be contributing to her insomnia and uncontrolled diabetes. Medication adjustments as well as when can be adjusted to safely control the symptoms of the patient.

· List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why. 

The differential diagnosis that I would choose would be MDD and insomnia disorder. The patient has experienced a loss and is trying to cope but her body’s way of coping is causing an imbalance in the brain, and causing her anxiety, and can be exacerbating the depression, hence, the insomnia, the sleeping habits changing. Insomnia disorder is described by an extreme amount of distress or impairment in operation, and daytime symptoms including fatigue, daytime tiredness, cognitive impairment, and mood disturbances (Levenson et al., 2015).

· 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. 

I would continue with the current regimen, sertraline 100mg daily, because the decrease in serotonin, the medication will work, and in adjunct with a benzodiazepine (BZD) to treat the anxiety that she is having which should help keep the patient calm, assist with stabling her mood and body so her vitals are lower. Lormetazepam was mostly prescribed in women with psychiatric issues and insomnia (Cosci et al., 2016). The combination of the two working on the perspective areas of the brain decreasing the physical signs and symptoms is the goal.

· 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?

What would be problematic would be if this becomes a long-term regimen, that the patient, depending upon her socio-demographics may possibly become addicted to the BZD (Cosci et al., 2016).

· 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.

After six weeks of treatment with a selective serotonin reuptake inhibitor (SSRI), she should show significant clinical improvements which would be evident by the significant improvements (Dutt et al., 2020). Continue the regimen for the depression and assess if the symptoms for GAD has decreased. If so, slowly take the patient off the BZD while educating her as what to do nonpharmacological to assist with her symptoms when they arise.

References

Cosci, F., Mansueto, G., Faccini, M., Casari, R., & Lugoboni, F. (2016). Socio-demographic and

clinical characteristics of benzodiazepine long-term users: Results from a tertiary care

center. Comprehensive Psychiatry, 69, 211–215.     

https://doi.org/10.1016/j.comppsych.2016.06.008

Dutt, R., Shankar, N., Srivastava, S., Yadav, A., & Ahmed, R. S. (2020). Cardiac autonomic

tone, plasma BDNF levels and paroxetine response in newly diagnosed patients of

generalised anxiety disorder. International Journal of Psychiatry in Clinical

Practice, 24(2), 135–142. https://doi.org/10.1080/13651501.2020.1723642

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia.

Chest, 147(4), 1179–1192. https://doi.org/10.1378/chest.14-1617

Oyama, O. & Piotrowski, N. A. (2021). Depression. Magill’s Medical Guide (Online Edition).

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