680 responses

MondayMay 17 at 9:33am

With the case study provided, the information is divided into four different categories with the SOAP method.

Subjective

This case study had plenty of subjective information from the patient. She stated that she is missing days of work almost every week, neglecting her family, sleeping during the day, and not sleeping at night. In addition to that, she denied any other health problems, medication history, or environmental allergies.

Objective

There is only one objective information that was described in this case study, which was that the patient is a 52 year old woman. To further assess for more objective information, I would want to focus on three types of information I can draw from by talking with the patient. First, focusing on her appearance would provide good information about the patient, specifically looking at her posture, body movements, dress, grooming, and hygiene (Jarvis & et al., 2020). Second, I would focus on her behavioral cues like her facial expression, speech, mood, and affect. Third, I would assess her cognition by asking about facts of herself like her birthday, name, and the date.

Assessment

In order to properly assess the patient, I would first take her vital signs: blood pressure, heart rate, temperature, and oxygen saturation. After that, I would take a listen to her heart and lungs.

Once this part of the assessment is completed, I would ask some more questions regarding her new symptoms she is coming in for. The method I would use is the acronym COLDSPA, which stands for character, onset, location, duration, severity, pattern, and associated factors (Dains & et al., 2020). This would help in determining what other symptoms she may be having.

In addition to asking about her new symptoms, I would do an assessment focusing on her health history and her functional status. First, with her health history, I would ask about her present health, past health concerns, her current and past medications, and history about her family (Dains & et al., 2020). Second, for her functional assessment, I would try to gather information to learn more about the environmental factors in her life that may contribute with her health, which include economic status, home environment, health promotion, and interpersonal relationships (Dains & et al., 2020).

After this assessment and looking at her overall health history and environmental influences, I would be able to determine some problems that this patient may be having. One of the problems that I noticed is that the patient may be at risk for depression or another mental health disorder. The next step would be to plan care individualized to this patient.

Plan

To address the concerns and problems seen with this patient, I would plan to assess her even further with some diagnostic tests. I would plan to draw her blood and get a complete blood count, hemoglobin A1c, a basal metabolic panel, and electrolyte levels. This can help to address where some of the problems may be originating from. Another diagnostic test I would do is a mental health test to determine whether or not the patient has any mental health disorder. An example of this is a depression screening. In addition to these diagnostic tests, I would recommend some non-pharmacological interventions to help with sleep like not utilizing electronic devices prior to sleeping, drinking tea, and trying some fragrances. In regard to pharmacological interventions, I would not prescribe anything specifically until all the diagnostic tests have been done. And, to end the session with this patient, I would set a follow up appointment.

References:

Dains, J. E., Baumann, L. C., & Scheibel, P. (2020). Advanced health assessment and clinical diagnosis in primary care. Elsevier.

Jarvis, C., Eckhardt, A., & Thomas, P. (2020). Physical examination & health assessment. Elsevier.

TuesdayMay 18 at 12:02pm

Hi Moses,

Great post this week! Your post was neat, and you provided us with a lot of information. You mentioned that the patient may be at risk for depression or another mental health disorder. I agree with this statement. What diagnosis do you have for this patient? What differential diagnosis do you have? I would also check the patient’s thyroid function, as this could be an underlying health issue that may be contributing with her sleepiness and depression. Would you also recommend her to see a therapist for her depression? If her lab values come back WNL and you diagnose her with depression which pharmacological agent would you prescribe?

TuesdayMay 18 at 12:36pm

Hi Moses,

Thank you for sharing your plan, I liked your choice to test and wait for the results. What would be your preliminary diagnosis based on her subjective symptoms? The inclusion of a functional assessment will yield valuable information about her home environment (particularly noise pollution), family relationship (role strain, risk for domestic abuse, or recent stress events), and her sleep habits (how many hours? What time does she go to sleep? Is she drinking caffeine before bed?) (Jarvis, 2015). We have more subjective data provided than objective which also warrants a mental status exam for her to assess her psychological stability. The BATHE model is helpful for situational stress if her symptoms are recent by asking background information of any recent life changes, how she feels about it, the trouble the situation has brought, and how they are coping with those changes (Daines et al., 2015). For objective data, the mental status exam that uses the ABCT concept to assess for appearance, behavior, cognitive function, thought process, and the Mini-Mental State Examination can offer further insight (Jarvis, 2015). The elimination of caffeine and alcohol, regular exercise, and setting a bedtime that gives her at least eight hours can also assist in controlling symptoms. What type of relaxation teas for inducing sleep would you recommend?

References

Daines, J. E., Baumann, L. C. and Scheibel, P. (2015) Advanced Health Assessment & Clinical Diagnosis in Primary Care (5th ed.). Elsevier

Jarvis, C. (2015). Physical Examination and Health Assessment (7th ed.). Elsevier

TuesdayMay 18 at 7:44pm

Hi Moses,

What would your dx and differentials be?

Thank you,

Dr. Mills

WednesdayMay 19 at 11:11am

My Revised SOAP Note

With the case study provided, the information is divided into four different categories with the SOAP method.

Subjective

Objective

In order to properly assess the patient, I would first take her vital signs: blood pressure, heart rate, temperature, and oxygen saturation. After that, I would take a listen to her heart and lungs.

Assessment

Plan

References:

Dains, J. E., Baumann, L. C., & Scheibel, P. (2020). Advanced health assessment and clinical diagnosis in primary care. Elsevier.

Jarvis, C., Eckhardt, A., & Thomas, P. (2020). Physical examination & health assessment. Elsevier.

ThursdayMay 20 at 6:18pm

Great post Moses,

I agree with your SOAP note, I see where your focus is and it all aims to ruling out depression. You asked the right questions and your are targeting all the right observatory assessments need to point out depression. I'd like to add some symptoms of depression:

· Feelings of sadness, tearfulness, emptiness or hopelessness

· Angry outbursts, irritability or frustration, even over small matters

· Loss of interest or pleasure in most or all normal activities, such as sex, hobbies or sports

· Sleep disturbances, including insomnia or sleeping too much

Stress is also something that often goes unnoticed and triggers many sleep disturbances. Stress coping techniques are also factor that need to be addressed and not ignored.

Mayo Clinic. 2021. Depression (major depressive disorder) - Symptoms and causes. [online] Available at: <https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007> [Accessed 21 May 2021].

Collapse Subdiscussion Shana Matatov

Shana Matatov

YesterdayMay 22 at 6:54pm

Moses,

Thank you for your post. Often, when I interview my patients, I realize that while I ask questions and they answer, they do not always tell me everything at first. Questions should be answered adequately so that the provider can get a good grasp on the patient and their concerns. This is either due to the patient not feeling comfortable or simply because the patient does not know. Therefore, I believe building a rapport with the patient is essential. Some helpful ways to make a rapport include communicating openly, keeping eye contact if culturally appropriate, empathizing with the patient, listening, and taking the time to get to know the patient (Nurse Choice, 2020). While this may sound time-consuming, the patient will feel more comfortable over time and will improve the care provided to the patient.

References

Nurse choice. (2020, July 30). How to build rapport with patients. https://www.nursechoice.com/blog/profiles-and-features/how-to-build-rapport-with-patients-7-effective-tips-for-rns/

YesterdayMay 22 at 6:57pm

Excellent! Besides listening to the patient, what is al important thing to do when asking the patient questions?

Dr. Mills

Collapse Subdiscussion Johana Cordova

Johana Cordova

YesterdayMay 22 at 9pm

Hello Moses,

I like the way you digested your information, giving focus to the complaints and details presented. I have noticed that to reach a diagnosis, your biggest focus was directed to the HPI, which involves a more question-answer interaction with the patients. This is the most important diagnostic process in patients presenting with depression (Dains et al., 2019).

In your plan, you mentioned considering both pharmacological and non-pharmacological interventions. Do you think non-pharmacological management of depression produces more positive results than pharmacological management? Personally I think that the non-pharmacological interventions provides more long lasting effects than the pharmacological management.

You stated that the patient age was the only objective information given, on the contrary, I think there was no objective information given at all. The patient's age should be part of the subjective information. According to Andrus et al., 2019, objective section comprises of information that is observed and measured by the physician.

Furthermore, you should consider widening your scope on various non pharmacological managements for depression. Psychotherapy has proven to produce more positive results in treatment of depression than medication (Berger et al., 2018).

References

Dains, J., Baumann, L., & Scheibel, P. (2019). Advanced health assessment & clinical diagnosis in primary care (6th ed.). St.Louis, MO: Elsevier Mosby. ISBN-13: 978-0323554961

Andrus, M. R., McDonough, S. L., Kelley, K. W., Stamm, P. L., McCoy, E. K., Lisenby, K. M., ... & Byrd, D. C. (2018). Development and validation of a rubric to evaluate diabetes soap note writing in APPE. American journal of pharmaceutical education, 82(9).

Berger, T., Krieger, T., Sude, K., Meyer, B., & Maercker, A. (2018). Evaluating an e-mental health program (“deprexis”) as adjunctive treatment tool in psychotherapy for depression: Results of a pragmatic randomized controlled trial. Journal of affective disorders, 227, 455-462.

MondayMay 17 at 11:54am

Considering our patients age we should think about if this patient is going through menopause or not. Most women enter menopause between the ages of 49 and 52 years, and the average age among women in the United States is 51 years (Koothirezhi, 2020). She complains of missing days of work every week, neglecting her family and sleeping during the day. This warrants immediate attention and makes me want to ask questions about her mental health. The health concerns among menopausal women are mainly related to vasomotor symptoms, urogenital atrophy, osteoporosis, cardiovascular disease, cancer, psychiatric symptoms, cognitive decline, and sexual problems (Koothirezhi, 2020). I would use the PHQ-2 screening tool as it measures the severity of depression. If the patient answers several days or highs then PHQ-9 should be used (Jarvis, 2015). I would first start the interview process asking the patient how they are feeling today and then focus the questions on her mental health and reproductive health. I would ask at what age did she start her period, when was her last period and what is her flow like. After questions about her reproductive health then discuss her mental health. I would ask questions directly from the PHQ-2/PHQ-9. I would also ask if she has any stress in her life and how she copes with that. Is she on any medication? Does she have a social support? Does she have any diseases or conditions? Does she have a history or mental health issues or does any one in the family have mental health issues? I would want a lab work drawn up of CBC, thyroid function, vitamin B, folate, basic metabolic and urine sample to rule out any other underlying issues.

· Pertinent positive: she has been missing days of work almost every week, she states she is neglecting her family, and she is sleeping during the day but cannot sleep at night.

· negative information: denies other health problems, medication, or environmental allergies.

· Differential and working diagnosis: Major depressive disorder, postmenopausal syndrome

· Treatment plan, including: Hormone replacement therapy, SSRI, Psychotherapy

· Labs: CBC, thyroid function, vitamin B, folate, basic metabolic and urine sample

· health education: Discuss with patient that the antidepressants can take a couple of weeks to work. Discuss adverse side effects and what to look for. If patient does not like side effects can switch to another medication.

· lifestyle changes: Increase exercise, maintain healthy diet, modify sleep pattern

· follow-up with patient in 4-6 weeks and refer patient psychotherapy

Bromberger, J. T., & Epperson, C. N. (2018). Depression During and After the Perimenopause: Impact of Hormones, Genetics, and Environmental Determinants of Disease. Obstetrics and gynecology clinics of North America, 45(4), 663–678. https://doi.org/10.1016/j.ogc.2018.07.007

Jarvis, C. Physical Examination and Health Assessment. [VitalSource Bookshelf]. Retrieved from https://online.vitalsource.com/#/books/9781455728107/

Koothirezhi R, Ranganathan S. Postmenopausal Syndrome. [Updated 2020 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560840/

Park, L. T., & Zarate, C. A., Jr (2019). Depression in the Primary Care Setting. The New England journal of medicine, 380(6), 559–568. https://doi.org/10.1056/NEJMcp1712493

Collapse Subdiscussion Kelly Vasquez Garcia

Kelly Vasquez Garcia

TuesdayMay 18 at 5:56pm

Hello Alyssa Morales,

In reading your post and based on patient signs and symptoms I agree with your primary and possible differential diagnosis. “But the physical symptoms, such as hot flashes, and emotional symptoms of menopause may disrupt your sleep, lower your energy or affect emotional health” (MayoClinic, 2021). If patient is diagnosed with menopause after thorough assessment then ERT / HRT would be discussed with the patient. “Preventative Services Task Force (USPSTF), and the U.S. Food and Drug Administration (FDA) support the use of ERT/HRT for the treatment of moderate to severe menopausal symptoms” (Woo & Robinson, 2020, p 1152). You also mentioned possible treatment of SSRI and or psychotherapy; however for purpose of discussion I would speak to patient about alternative less invasive means as well (unless blood work demonstrates otherwise). This would include considering phytoestrogens, botanicals, and herbs. If sleep deprivation is found to be acute melatonin would be a good option while symptoms resolve. This is assuming there is life change causing worry or stress preventing sleep. Adding to the education you provided I feel it is important to provide education on how to enhance sleep at night and diary keeping of sleep habits. I would also educate on when to seek emergency services immediately such as suicidal ideation or thoughts to hurt self / others. You provided great post and plan of care.

Respectfully,

Kelly Vasquez Garcia

References:

MayoClinic. (2021). Menopause. Retrieved from https://www.mayoclinic.org/diseases-conditions/menopause/symptoms-causes/syc-20353397 (Links to an external site.)

Woo, T. & Robinson, M. (2020). Pharmacotherapeutics for Advanced Practice Nurse Prescribers (5th ed.). Philadelphia, PA: F.A. Davis Company

WednesdayMay 19 at 7:53am

Subjective: complains that she has been missing days of work almost every week, she states she is neglecting her family, and she is sleeping during the day but cannot sleep at night. She denies other health problems, medication, or environmental allergies.

Objective: 52-year-old female, vital signs including height and weight would go here

Assessment: Major depressive disorder, postmenopausal syndrome

Plan: Draw labs including CBC, thyroid function, vitamin B, folate, basic metabolic and urine sample. After labs come back design a plan according to that.

Plan: For menopausal symptoms Hormone replacement therapy, for depression SSRI, for depression Psychotherapy. Discuss with patient that the antidepressants can take a couple of weeks to work. Discuss adverse side effects and what to look for. If patient does not like side effects can switch to another medication. Increase exercise, maintain healthy diet, modify sleep pattern. Follow-up with patient in 4-6 weeks and refer patient psychotherapy. If patient develops suicidal ideations call immediately and go to the ER.

Collapse Subdiscussion Elin Minassian

Elin Minassian

FridayMay 21 at 4:17pm

Alyssa,

I enjoyed reading your treatment plan and evaluation for this patient. Per the information provided, I agree with your diagnoses and like how you correlated her depression with menopause considering the age bracket she is in. " Major depression is a condition associated with a chemical imbalance in the brain, and changing hormones during pre-menopause may be associated with that imbalance" (Depression & Menopause, 2021). Depressive symptoms are widespread in all demographics, although they tend to be more prevalent in women going through menopause. I believe that the hormonal changes that the body experiences during menopause can have a direct affect on a woman's mental health. As providers it is crucial for us to conduct a very thorough assessment to make a precise diagnosis. Throughout our assessment it is critical for us to assess and determine if patients have been experiencing symptoms consistently for a period of two weeks or more, and which symptoms are they experiencing, by doing so it will be easier to narrow down if patients are feeling depressed.

Depression & Menopause. Menopause & Depression, Mood Changes | The North American Menopause Society, NAMS. (2021). https://www.menopause.org/for-women/menopauseflashes/mental-health-at-menopause/depression-menopause.

WednesdayMay 19 at 12:09pm

Hi Alyssa,

Thank you for sharing your care plan for the patient, I enjoyed reading its detail. I really liked how you included the bloodwork for assessing her thyroid function since elevated thyroid-stimulating hormone (TSH) and lack of sleep is pertinent for hyperthyroidism. The patient certainly falls in line with the average age of menopause and the transition can affect daily life with the onset of hot flashes, sleep disturbances, and changes in mood. Lack of sleep, stress, and low mood from these changes can manifest in impaired memory and difficulty concentrating (Noble, 2018). The subjective evidence presented of her insomnia, missing work, and neglecting her family can also subject her to anxiety or depression. For finding objective data, I like how you branch out into detecting underlying health conditions such as nutritional deficiencies, endocrinology, anemia, or electrolyte imbalances. In terms of medications, what hormone replacement therapy options would you think of prescribing her? Would you recommend any complementary-alternative medicine (CAM) options if she asked?

References

Noble, N. (2018). Symptom management in women undergoing menopause. Nursing Standard, 32(22), 53-62. 10.7748/ns.2018.e11041

WednesdayMay 19 at 10:53pm

Hello, Alyssa. Thank you for your post. As you mentioned, thyroid dysfunction is associated with numerous neuropsychiatric disorders such as depressive clinical manifestation, maniac behaviors, cognitive disorders, and acute psychosis (Hong et al., 2018). Studies show untreated hypothyroidism induces an increased risk for depression (Hong et al., 2018). Also, thyroid function tests are the most frequently measurements endocrine laboratory tests for a depression diagnosis in primary care health settings (Hong et al., 2018). Subclinical hypothyroidism and subclinical hyperthyroidisms are abnormal high and low serum thyroid-stimulating hormone (TSH) levels with a normal serum free thyroxine (fT4) level, which lack clinical manifestation in patients (Hong et al., 2018). These disorders are more widespread than hypothyroidism or hyperthyroidism. Depression is one of the most prevalent mental disease disorders, with considerable high morbidity and mortality (Hong et al., 2018). Our fifty-two-year-old patient, as you mentioned she be best to get assessed for subclinical thyroid dysfunctions. Consideration for other measures such as the 9-item Patient Health Questionnaire (PHQ-9), a self-report tool for screening depression based on typical and global criteria, is reliable and valid to determine the acuity of depression (Hong et al., 2018).

References

Hong, J. W., Noh, J. H., & Dong-Jun Kim. (2018). Association between subclinical thyroid dysfunction and depressive symptoms in the Korean adult population: The 2014 Korea National Health and Nutrition Examination Survey. PLoSOne, 13(8).

http://dx.doi.org.westcoastuniversity.idm.oclc.org/10.1371/journal.pone.0202258

MondayMay 17 at 3:36pm

Subjective:

Chief complaint: A 52-year-old female presents with the chief complaint of “missing days of work every week and cannot sleep at night”.

History of Present Illness: Patient states she is neglecting her family, sleeping during the day, but cannot sleep at night. Symptoms have affected daily life.

· Questions that the patient can be asked for further information would be: When did sleeplessness begin? How many times a week does this occur? When does she normally go to sleep? Are there any triggering factors for the sleepless nights (fatigue, coffee, stress, activity, weather)? Does she have any pain, fever, restlessness, or night sweats that interfere with sleep? Has she tried anything to relieve it (meditation, over-the-counter medications, herbal tea)? How many hours of sleep is she receiving on average during the night versus daytime? What are her current sleeping habits? Where does she sleep in her household? Is it a quiet environment? Does she wake feeling rested or fatigued?

Past medical history: Patient reports no health problems, medication, or environmental allergies.

· Questions that the patient can be asked for further information would be: Any family history of psychological or endocrinological problems? Has the patient been recently taking any over-the-counter or herbal supplements?

Review of Systems:

General: Has she had any recent weight loss or gain? Recent changes in diet? Fatigue? Night sweats? Hyperthyroidism and menopause can cause changes in sleep, weight, and appearance (Daines et al., 2015) Hair: Any recent hair loss? Changes in texture or thinning? Skin: Any changes in skin texture? Thinning of skin? Sensitivity to heat? How much exposure to the sun does she receive daily? Head: Do headaches accompany or trigger the symptoms? Any changes in memory? Eyes: Any recent changes in vision? Eye pain? Ears: Any recent episodes of tinnitus or vertigo? Earache? Heavy exposure to environmental noise? Nose: Any pain, changes in smell, or congestion? Throat: Any dryness in the mouth, sore throat, or hoarseness in voice when waking? Sleep apnea can also disrupt nightly sleep and cause sleepiness and fatigue during the daytime (Daines et al., 2015). Neck: Has she noticed swelling or lumps in her neck? Any pain in the neck area? Breasts: When was her last mammogram? Does she do monthly self-exams? Has she noticed changes in her breast tissue? Any lumps or masses? Respiratory: Any shortness of breath, coughing with sputum, or recent pollution exposure? When was her last TB test? Cardiovascular: Has she had any heart palpitations, tachycardia at home when resting, dyspnea on exertion, or nocturnal dyspnea? Peripheral Vascular: Any swelling, coldness, tingling, or discoloration of the hands or feet? Gastrointestinal: How is her appetite? Any recent diet changes? Food intolerances? Nausea, abdominal discomfort, excess gas with meals? Any new changes in bowel movements? Urinary: Any recent nocturia or dysuria? Urogenital: Is she sexually active? Are condoms used routinely? Has a recent partner been diagnosed with a sexually transmitted disease? Any changes in urination or vaginal discharge? Is she still menstruating? When was her last menstrual cycle? Have her menstruation cycles been regular? Has she had any night sweats or hot flashes recently? Any decreased libido and vaginal dryness? Musculoskeletal: Any recent bone pain or joint stiffness? Neurologic: Has she had any new tremors, weakness, or coordination problems? Any problems with short-term or long-term memory? Any mood changes such as anxiety, depression, or sudden anger? Endocrine: Any recent intolerance to heat or cold? Excessive sweating? Any polydipsia, polyuria, and polyphagia?

Functional Assessment:

· Questions to ask: Any recent stressors to her daily life? Family role strain? Work stress? Financial stress? Does she feel safe at home or experiencing domestic partner violence? Any recent alcohol, smoking, or street drug use? Any positive response to this question can prompt the CAGE test for further alcohol abuse assessment (Daines et al., 2015). The patient would also benefit from a depression and anxiety screening, such as the GAD-7, to rule out potential risk from the lack of sleep and reports of family neglect (Daines et al., 2015). She can be asked about her coping strategies for stress and what has worked.

Objective:

General: Vital signs need to be obtained for this patient for a baseline as well as measuring her height and weight. A total body mass index can be obtained which guides treatment while at the same time, changes in height can provide pertinent positive or negative findings for osteoporosis risk. Assessment is required about the patient’s grooming, appropriate attire for the weather, and nourished condition. Hair: Assess for thinning strands that can correlate to positive findings for hyperthyroidism. Skin: Inspect for thinning changes, texture, excess sweating, and bruising. Moist, warm, and thin skin along with fine, silky hair are common positive findings of hyperthyroidism (Mayo Clinic, 2020). Neurological: Inspect the hands for fine tremors and assess deep tendon reflexes, which are usually brisk in hyperthyroidism (Mayo Clinic, 2020). HEENT: Assessment of the eyes for diplopia, lid lag, and ptosis are positive findings for hyperthyroidism. A healthy patient should have equally sized pupils, round and reactive to light, intact extraocular movements are intact, and clear conjunctiva. No discharge, inflammation, or hemorrhages should be present. Inspection of the ear canals should be clear with a translucent tympanic membrane. Inspection of the oral mucosa should be clear of ulcerations, erythema, or exudate. Presence of lesions can be a pertinent positive finding for undetected sexually transmitted diseases that can cause neurologic and psychological changes such as neurosyphilis (Woo & Robinson, 2020). Palpation of the neck for lumps or masses along the thyroid can assess for hyperthyroidism. Breast: Inspect the skin for thinning or decreased elasticities and palpate for masses or lymphadenopathy. Heart: Auscultate for any murmurs, bruit, and irregular rate for abnormalities. Atrial fibrillation is common with hyperthyroidism as a pertinent positive finding while a negative finding would rule out the symptoms, leaning towards menopause, a nutritional deficiency, or psychological disorder (Daines et al., 2015). Palpation of the pulses on all extremities can yield negative findings for cardiovascular complications and endocrinological influence. Respiratory: Auscultate lungs, anterior and posteriorly, to rule out wheezing and crackles. Assessment of the patient’s oxygenation status can provide a pertinent positive finding if it is low because it can affect a patient’s energy levels and hypoxia to the brain can affect daily life. Abdomen: Palpate the lower quadrants for rebound guarding or tenderness which can yield a positive pertinent finding for pelvic inflammatory disease, urogenital problems, and other sexually transmitted diseases that affect the lower abdomen. A nondistended, non-tender abdomen with bowel sounds in all quadrants and no jaundice or bruising on the skin rules out gastrointestinal diagnoses. Urogenital: Inspect the vulva for any lesions, warts, vesicles, skin ulcerations, periurethral abscesses, abnormal vaginal discharge, cervical tenderness, vulvar/vaginal/cervical masses, or uterine tenderness. Pertinent positive findings such as these can rule-in sexually transmitted diseases, menopause, or cancer. Pelvic: Inspect for vaginal atrophy, dryness, and weakness of the pelvic floor for pertinent positive findings of menopause. Musculoskeletal: Inspect the patient’s spine for kyphosis for osteoporosis risk that accompanies menopause. Psychiatric: Assess the patient for appropriate mood, affect, attention span, and thought and speech patterns. Has she had any thoughts of hopelessness, sadness, nervousness, sudden mood changes, or thoughts of self-harm?

Assessment:

Working Diagnosis:

· Menopause

The patient’s positive pertinent findings of being a female of 52 years of age, inability to sleep at night, and sleeping during the day. The diagnosis should be made based on the woman’s age, assessment of symptoms, and menstrual history (Noble, 2018). Pertinent positive findings for this diagnosis with patients are hot flashes, night sweats, vaginal dryness, suboptimal sleep, impaired memory, difficulty concentrating, joint pain, mood changes, urinary frequency and loss of libido (Noble, 2018).

Differential Diagnosis:

· Anxiety

The patient has positive pertinent findings of trouble sleeping and missing work. Other positive pertinent findings with this condition are trouble concentrating, hypervigilance, heart palpitations, a feeling of impending doom, and insomnia (Daines et al., 2015). A mental status assessment with positive responses to these symptoms will rule-in this diagnosis.

· Depression

The patient’s positive pertinent finding is neglecting family, frequently missing work, and inability to sleep at night, and daytime sleeping. Pertinent positive findings are symptoms that have persisted over two weeks such as sadness, hopelessness, difficulty sleeping, restlessness, difficulty concentrating, changes in appetite, and fatigue (Daines et al., 2015). A depression scale and mental assessment will yield pertinent positive results if she has these symptoms.

· Hyperthyroidism

The patient’s positive pertinent finding is trouble sleeping at night. Positive pertinent findings with these patients are elevated TSH levels, enlarged thyroid, difficulty sleeping, sweating, heat intolerance, weight loss, tremors, tachycardia, and nervousness (Mayo Clinic, 2020). Laboratory work will confirm this differential diagnosis.

Plan:

Laboratory orders:

Complete blood count with indices and differential: The complete blood count (CBC) will provide information about the presence of infection or anemia.

Follicle stimulating hormone (FSH) and estradiol levels: FSH will be elevated to 30 mIU/mL or higher and estradiol will be low for menopausal women (The North American Menopause Society, 2020).

Serum electrolytes: Symptoms of depression can be exacerbated by hyponatremia, hypernatremia, hypercalcemia, and hyperphosphatemia (Daines et al., 2015).

Thyroid-stimulating hormone: An elevated level of thyroid-stimulating hormone (TSH) is related to chronic symptoms of depression and can also be associated with anxiety (Mayo Clinic, 2020).

Toxicology screen to rule out substance abuse and urine screen for potential pregnancy if hormone-therapy replacement (HRT) is needed.

Serum B12 and vitamin D levels for a nutritional deficiency that can exacerbate depression symptoms (Daines et al., 2015).

Rapid plasma regain (RPR): Patients with undetected syphilis can mimic neurologic disease and affect mental well-being and cognitive function in neurosyphilis (Daines et al., 2015).

Diagnostic testing:

A mammogram should be ordered if the patient has not had one in the last two years before starting HRT (Woo & Robinson, 2020).

Medications:

The first-line treatment for controlling menopause symptoms is a low-dose hormone replacement. Prempro 0.3 mg/1.5 mg once daily by mouth can be prescribed due to the evidence-based research to relieve vasomotor symptoms (Woo & Robinson, 2020). Depending on the patient’s history, she can have estrogen-only HRT (such as Premarin) if she has no uterus but women with an intact uterus require combination estrogen-progesterone (Noble, 2018).

If the patient wishes to try non-hormonal means first, then she can be prescribed paroxetine 20mg by mouth once daily alongside lifestyle modifications (Woo & Robinson, 2020). This medication is also given for treating both depression and anxiety if the working diagnosis is ruled out for a psychological condition from the differential diagnosis.

Patient Education:

The patient was provided with education on what to expect with menopause, including the physiologic, mental, and physical changes that take place. Reading material and websites were provided for the patient to study at home.

A discussion of hormonal versus non-hormonal therapy and alternative therapy with the patient was discussed. The patient’s risks for hormone replacement therapy consideration and her eligibility were acknowledged.

The patient was instructed on behavioral modification to increase daily aerobic exercises such as daily walking, bone-strengthening exercises such as weightlifting, smoking cessation, eliminating caffeine and alcohol from her diet, and increasing vitamin D and calcium-rich foods in her diet (Woo & Robinson, 2020). Deep breathing and meditation can assist with relaxation before sleeping. The patient was encouraged to keep a diary to catalog symptoms, sleep patterns, sleep hours, and aggravating/alleviating factors for the next follow-up.

The patient was educated regarding low-dose hormone replacement therapy. Vasomotor symptoms will begin to decrease by the second week of therapy and reach maximal effect by the eighth week of therapy (Woo & Robinson, 2020). Side effects of mild nausea, breast tenderness, or midcycle spotting during the first two months of therapy discussed. Patient informed to report adverse effects such as leg pain, visual disturbances, and severe headache.

The patient was informed that a low-dose selective serotonin reuptake inhibitor (SSRI) such as paroxetine can assist with vasomotor relief, mood stability, and sleep regulation from menopause. Discussed that there is a greater risk of suicide within the first 3 weeks of taking SSRIs and for her to not stop taking them abruptly. She was educated on not using alcohol while on this medication, along with aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) that can increase bleeding risk. Advised the patient that SSRIs may take as long as 3 to 4 weeks until therapeutic benefit becomes evident. Discussed initial adverse reactions, commonly including nausea, intermittent light-headedness, sedation, muscle restlessness, and sleep disruptions.

Follow-up:

The patient will follow up in two weeks but if symptoms worsen, she must return sooner. If any thoughts of self-harm or changes in mood occur, she must return promptly for reassessment. The patient was also informed that she will be contacted sooner if bloodwork returns abnormally. If insomnia relief is not achieved at the expected time frame, the HRT dose can be adjusted as highly as 0.625 mg/5 mg as well as the alternative option of sertraline.

References

Daines, J. E., Baumann, L. C. and Scheibel, P. (2015) Advanced Health Assessment & Clinical Diagnosis in Primary Care (5th ed.). Elsevier

Mayo Clinic. (2020, November 14). Hyperthyroidism. https://www.mayoclinic.org/diseases-conditions/hyperthyroidism/symptoms-causes/syc-20373659 (Links to an external site.)

Noble, N. (2018). Symptom management in women undergoing the menopause. Nursing Standard, 32(22), 53-62. 10.7748/ns.2018.e11041

The North American Menopause Society. (2020). Menopause 101. https://www.menopause.org/for-women/menopauseflashes/menopause-symptoms-and-treatments/menopause-101-a-primer-for-the-perimenopausal (Links to an external site.)

Woo, T.M, & Robinson M.V. (2020). Pharmacotheurapetics for Advanced Practice Nurse Prescribers (5th ed). F.A Davis Company

WednesdayMay 19 at 4:36am

Near perfection and encompassed the instructions!

What would a side effect of an antidepressant be that you would want to warn the patient about and that often leads to patients not taking it?

Thank you,

Dr. Mills

WednesdayMay 19 at 11:59am

Hi Dr. Mills, thank you and I am resubmitting with a clearer version of my SOAP note.

Subjective:

· Chief complaint: A 52-year-old female presents with the chief complaint of “missing days of work every week”.

· History of Present Illness: Patient states she is neglecting her family, sleeping during the day, but cannot sleep at night. Symptoms have affected daily life.

· Past medical history: Patient reports no health problems, medication, or environmental allergies.

· Review of Systems:

· General: Has she had any recent weight loss or gain? Recent changes in diet? Fatigue? Night sweats? Hyperthyroidism and menopause can cause changes in sleep, weight, and appearance (Daines et al., 2015)

· Hair: Any recent hair loss?

· Skin: Any changes in skin texture? Thinning of skin? Sensitivity to heat? How much exposure to the sun does she receive daily?

· Head: Do headaches accompany or trigger the symptoms? Any changes in memory?

· Eyes: Any recent changes in vision? Eye pain?

· Ears: Any recent episodes of tinnitus or vertigo? Earache? Heavy exposure to environmental noise?

· Nose: Any pain, changes in smell, or congestion?

· Throat: Any dryness in mouth, sore throat, or hoarseness in voice when waking?

· Neck: Has she noticed swelling or lumps in her neck? Any pain in the neck area?

· Breasts: When was her last mammogram? Does she do monthly self-exams? Has she noticed changes in her breast tissue? Any lumps or masses?

· Respiratory: Any shortness of breath, coughing with sputum, or recent pollution exposure? When was her last TB test?

· Cardiovascular: Has she had any heart palpitations, tachycardia at home when resting, dyspnea on exertion, or nocturnal dyspnea?

· Peripheral Vascular: Any swelling, coldness, tingling, or discoloration of the hands or feet?

· Gastrointestinal: How is her appetite? Any recent diet changes? Food intolerances? Nausea, abdominal discomfort, excess gas with meals? Any new changes in bowel movements?

· Urinary: Any recent nocturia or dysuria?

· Urogenital: Is she sexually active? Are condoms used routinely? Has a recent partner been diagnosed with a sexually transmitted disease? Any changes in urination or vaginal discharge? Is she still menstruating? When was her last menstrual cycle? Have her menstruation cycles been regular? Has she had any night sweats or hot flashes recently? Any decreased libido and vaginal dryness?

· Musculoskeletal: Any recent bone pain or joint stiffness?

· Neurologic: Has she had any new tremors, weakness, or coordination problems? Any problems with short-term or long-term memory? Any mood changes such as anxiety, depression, or sudden anger?

· Endocrine: Any recent intolerance to heat or cold? Excessive sweating? Any polydipsia, polyuria, and polyphagia?

· Functional Assessment:

· Questions to ask: Any recent stressors to her daily life? Family role strain? Work stress? Financial stress? Does she feel safe at home or experiencing domestic partner violence? Any recent alcohol, smoking, or street drug use? Any positive response to this question can prompt the CAGE test for further alcohol abuse assessment (Daines et al., 2015). The patient would also benefit from a depression and anxiety screening, such as the GAD-7 and PHQ-9, to rule out potential risk from the lack of sleep and reports of family neglect (Daines et al., 2015). She can be asked about her coping strategies for stress and what has worked.

Objective:

· General: The only objective data given was the patient is a 52-year-old female which warrants more investigation. Vital signs need to be obtained for this patient for a baseline as well as measuring her height and weight. A total body mass index can be obtained which guides treatment while at the same time, changes in height can provide pertinent positive or negative findings for osteoporosis risk. Assessment is required about the patient’s grooming, appropriate attire for the weather, and nourished condition.

· Hair: Assess for thinning strands which can correlate to positive findings for hyperthyroidism.

· Skin: Inspect for thinning changes, texture, excess sweating, and bruising. Moist, warm, and thin skin along with fine, silky hair are common positive findings of hyperthyroidism (Mayo Clinic, 2020).

· Neurological: Inspect the hands for fine tremors and assess deep tendon reflexes, which are usually brisk in hyperthyroidism (Mayo Clinic, 2020).

· HEENT: Assessment of the eyes for diplopia, lid lag, and ptosis are positive findings for hyperthyroidism. A healthy patient should have equally sized pupils, round and reactive to light, intact extraocular movements are intact, and clear conjunctiva. No discharge, inflammation, or hemorrhages should be present. Inspection of the ear canals should be clear with a translucent tympanic membrane. Inspection of the oral mucosa should be clear of ulcerations, erythema, or exudate. Presence of lesions can be a pertinent positive finding for undetected sexually transmitted diseases that can cause neurologic and psychological changes such as neurosyphilis (Woo & Robinson, 2020). Palpation of the neck for lumps or masses along the thyroid can assess for pertinent positive findings of hyperthyroidism.

· Breast: Inspect the skin for thinning or decreased elasticities and palpate for masses or lymphadenopathy.

· Heart: Auscultate for any murmurs, bruit, and irregular rate for abnormalities. Atrial fibrillation is common with hyperthyroidism as a pertinent positive finding while a negative finding would rule-out the symptoms, leaning towards menopause, a nutritional deficiency, or psychological disorder (Daines et al., 2015). Palpation of the pulses on all extremities can yield negative findings for cardiovascular complications and endocrinological influence.

· Respiratory: Auscultate lungs, anterior and posteriorly, to rule out wheezing and crackles. Assessment of the patient’s oxygenation status can provide a pertinent positive finding if it is low because it can affect a patient’s energy levels and hypoxia to the brain can affect daily life.

· Abdomen: Palpate the lower quadrants for rebound guarding or tenderness which can yield a positive pertinent finding for pelvic inflammatory disease, urogenital problems, and other sexually transmitted diseases that affect the lower abdomen. A nondistended, non-tender abdomen with bowel sounds in all quadrants and no jaundice or bruising on the skin rules out gastrointestinal diagnoses.

· Urogenital: Inspect the vulva for any lesions, warts, vesicles, skin ulcerations, periurethral abscesses, abnormal vaginal discharge, cervical tenderness, vulvar/vaginal/cervical masses, or uterine tenderness. Pertinent positive findings such as these can rule-in sexually transmitted diseases, menopause, or cancer.

· Pelvic: Inspect for vaginal atrophy, dryness, and weakness of the pelvic floor for pertinent positive findings of menopause.

· Musculoskeletal: Inspect the patient’s spine for kyphosis for osteoporosis risk that accompanies menopause.

· Psychiatric: Assess the patient for appropriate mood, affect, attention span, and thought and speech patterns. Conducting both the GAD-7 and PHQ-9 for anxiety and depression can yield either positive or pertinent findings.

Assessment:

· Working Diagnosis:

· Menopause

· The patient’s positive pertinent findings of being a female of 52 years of age, inability to sleep at night, and sleeping during the day. The diagnosis should be made based on the woman’s age, assessment of symptoms, and menstrual history (Noble, 2018). Pertinent positive findings for this diagnosis with patients are hot flashes, night sweats, vaginal dryness, suboptimal sleep, impaired memory, difficulty concentrating, joint pain, mood changes, urinary frequency, and loss of libido (Noble, 2018).

· Differential Diagnosis:

· Anxiety

· The patient has positive pertinent findings of trouble sleeping and missing work. Other positive pertinent findings with this condition are trouble concentrating, hypervigilance, heart palpitations, a feeling of impending doom, and insomnia (Daines et al., 2015). A mental status assessment with positive responses to these symptoms will rule-in this diagnosis.

· Depression

· The patient’s positive pertinent finding is neglecting family, frequently missing work, and inability to sleep at night, and daytime sleeping. Pertinent positive findings are symptoms that have persisted over two weeks such as sadness, hopelessness, difficulty sleeping, restless, difficulty concentrating, changes in appetite, and fatigue (Daines et al., 2015). A depression scale and mental assessment will yield pertinent positive results if she has these symptoms.

· Hyperthyroidism

· The patient’s positive pertinent finding is trouble sleeping at night. Positive pertinent findings with these patients are elevated TSH levels, enlarged thyroid, difficulty sleeping, sweating, heat intolerance, weight loss, tremors, tachycardia, and nervousness (Mayo Clinic, 2020). Laboratory work will confirm this differential diagnosis.

· Insomnia

· The patient reports subjective positive pertinent findings of difficulties sleeping. Inquiring further subjective data could yield positive pertinent findings if she has adequate time to sleep, wakes in the early morning, difficulty falling and maintaining sleep, and has trouble at least 3 nights per week for at least 3 months (Buysee et al., 2017).

Plan:

· Laboratory orders:

· Complete blood count with indices and differential: The complete blood count (CBC) will provide information about the presence of infection or anemia.

· Follicle stimulating hormone (FSH) and estradiol levels: FSH will be elevated to 30 mIU/mL or higher and estradiol will be low for menopausal women (The North American Menopause Society, 2020).

· Serum electrolytes: Symptoms of depression can be exacerbated by hyponatremia, hypernatremia, hypercalcemia, and hyperphosphatemia (Daines et al., 2015).

· Thyroid-stimulating hormone: An elevated level of thyroid-stimulating hormone (TSH) is related to chronic symptoms of depression and can also be associated with anxiety (Mayo Clinic, 2020).

· Toxicology screen to rule out substance abuse and urine screen for potential pregnancy if hormone-therapy replacement (HRT) is needed.

· Serum B12 and vitamin D levels for nutritional deficiencies that can exacerbate depression symptoms (Daines et al., 2015).

· Rapid plasma regain (RPR): Patients with undetected syphilis can mimic neurologic disease and affect mental well-being and cognitive function in neurosyphilis (Daines et al., 2015).

· Referral:

· Cognitive-behavioral therapy. The American College of Physicians (2017) recommends this type of psychotherapy be used with patients having sleep difficulties by fostering healthy sleep practices, stimulus control instructions, and relaxation training.

· Diagnostic testing:

· A mammogram should be ordered if the patient has not had one in the last two years before starting HRT (Woo & Robinson, 2020).

· Medications:

· The first-line treatment for controlling menopause symptoms is a low-dose hormone replacement. Prempro 0.3 mg/1.5 mg once daily by mouth can be prescribed due to the evidence-based research to relieve vasomotor symptoms (Woo & Robinson, 2020). Depending on the patient’s history, she can have estrogen-only HRT (such as Premarin) if she has no uterus but women with an intact uterus require combination estrogen-progesterone (Noble, 2018).

· If the patient wishes to try non-hormonal means first, then she can be prescribed paroxetine 20mg by mouth once daily alongside lifestyle modifications (Woo & Robinson, 2020). This medication is also given for treating both depression and anxiety if the working diagnosis is ruled out for a psychological condition from the differential diagnosis.

· Patient Education:

· The patient was provided with education on what to expect with menopause, including the physiologic, mental, and physical changes that take place. Reading material and websites were provided for the patient to study at home.

· A discussion of hormonal versus non-hormonal therapy and alternative therapy with the patient was discussed. The patient’s risks for hormone replacement therapy consideration and her eligibility were acknowledged.

· The patient was instructed on behavioral modification to increase daily aerobic exercises such as daily walking, bone-strengthening exercises such as weightlifting, smoking cessation, eliminating caffeine and alcohol from her diet, and increasing vitamin D and calcium-rich foods in her diet (Woo & Robinson, 2020). Deep breathing and meditation can assist with relaxation before sleeping. The patient was encouraged to keep a diary to catalog symptoms, sleep patterns, sleep hours, and aggravating/alleviating factors for the next follow-up.

· The patient was advised to set a consistent bedtime and wake time, to use her bed only for sleep, no using electronics in bed, keeping the room dark to induce sleep, and leaving the bed within 20 minutes if she can’t fall asleep (Buysee et al., 2017).

· The patient was educated regarding low-dose hormone replacement therapy. Vasomotor symptoms will begin to decrease by the second week of therapy and reach maximal effect by the eighth week of therapy (Woo & Robinson, 2020). Side effects of mild nausea, breast tenderness, or midcycle spotting during the first two months of therapy discussed. Patient informed to report adverse effects such as leg pain, visual disturbances, and severe headache.

· The patient was informed that a low-dose selective serotonin reuptake inhibitor (SSRI) such as paroxetine can assist with vasomotor relief, mood stability, and sleep regulation from menopause. Discussed that there is a greater risk of suicide within the first 3 weeks of taking SSRIs and for her to not stop taking them abruptly. She was educated on not using alcohol while on this medication, along with aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) that can increase bleeding risk. Advised the patient that SSRIs may take as long as 3 to 4 weeks until therapeutic benefit becomes evident. Discussed initial adverse reactions, commonly including nausea, intermittent light-headedness, sedation, muscle restlessness, and sleep disruptions.

· Follow-up:

· The patient will follow up in two weeks but if symptoms worsen, she must return sooner. If any thoughts of self-harm or changes in mood occur, she must return promptly for reassessment. The patient was also informed that she will be contacted sooner if bloodwork returns abnormally. If insomnia relief is not achieved at the expected time frame, the HRT dose can be adjusted as highly as 0.625 mg/5 mg as well as the alternative option of sertraline.

References

Buysse, D. J., Rush, A. J., & Reynolds, C. F. (2017). Clinical Management of Insomnia Disorder. JAMA, 318(20), 1973. doi:10.1001/jama.2017.15683

Daines, J. E., Baumann, L. C. and Scheibel, P. (2015) Advanced Health Assessment & Clinical Diagnosis in Primary Care (5th ed.). Elsevier

Mayo Clinic. (2020, November 14). Hyperthyroidism. https://www.mayoclinic.org/diseases-conditions/hyperthyroidism/symptoms-causes/syc-20373659 (Links to an external site.)

Noble, N. (2018). Symptom management in women undergoing the menopause. Nursing Standard, 32(22), 53-62. 10.7748/ns.2018.e11041

Woo, T.M, & Robinson M.V. (2020). Pharmacotheurapetics for Advanced Practice Nurse Prescribers (5th ed). F.A Davis Company

WednesdayMay 19 at 12:06pm

Hi Dr. Mills,

One side effect that often leads patients to not adhering to medication is that they may expect results within the week and that is not possible. A selective-serotonin reuptake inhibitor (SSRI) may take up to three weeks until the therapeutic benefit becomes evident which is important to inform the patients so they do not abruptly discontinue it (Woo & Robinson, 2020). Consistency and adherence are key, along with follow-up visits, and the patient should also be informed that providers usually start with the lowest doses to avoid side effects outweighing the benefit effects but doses can always be increased or the drug may be switched for another. At the same time, suicidal risk increases after the second week so patients must be thoroughly educated on reporting feelings of hopelessness and thoughts of self-harm to discontinue the medication (Woo & Robinson, 2020).

Reference:

Woo, T.M, & Robinson M.V. (2020). Pharmacotherapeutics for Advanced Practice Nurse Prescribers (5th ed). F.A Davis Company

ThursdayMay 20 at 7:23pm

Thank you. This is all true but I was looking for a true side effect of the medication. It is a side effect of most antidepressants.

Thank you,

Dr. Mills

FridayMay 21 at 7:15pm

Hello, Jasmin. Thank you for your post. Studies show a more overall rate of depressive disorder as mental health in women instead of the man. Works of literature and population research show the rate of hospitalizations, the number of suicidal attempts in individuals, and the increased amount of anti-depressant drugs dispense are growing. The overall rate of depression clinical manifestations in postmenopausal women is about twenty percent to twenty-five percent. The early postmenopausal women may be associated with a critical time that women require more detailed examination for depressive disorder. The diagnostic hormonal alteration in early menopausal women is accompanied by vasomotor signs and symptoms, which is called for a more thorough assessment for the risk of depression. According to the studies, the overall rate of depression is relatively high. About one in four postmenopausal women suffer from depression. The diagnosis of depression is related to improper functioning and diminished life quality. Depression is the main cause of neuropsychiatric disability for both men and women, but the torment of depressive disorder is fifty percent higher for women. Women are living longer than men. As older females experiencing an increase in morbidity, it is essential to recognize reducing risk factors that can enhance postmenopausal women's mental health and life quality.

References

Campbell, K. E., Szoeke, C. E., & Dennerstein, L. (2015). The course of depressive symptoms during the postmenopause: a review. Women's Midlife Health, 1, 1. http://dx.doi.org.westcoastuniversity.idm.oclc.org/10.1186/s40695-015-0003-x

Collapse Subdiscussion Kelly Vasquez Garcia

Kelly Vasquez Garcia

MondayMay 17 at 9:40pm

We know that patient is seeking care because she has been missing work related to not being able to sleep at night and sleeping during the day. Subjective information is description of fatigue / exhaustion from restless nights. This in turn has caused patient to neglect family. I would start with questions prior to physical exam after introduction. Questions would revolve around the following

· Biographic data to include ethnic origin, occupation, any recent change, and primary language,

· I would then obtain present health or history of present illness. This includes questions such as when did the symptoms first start and any attributing factors. Patient would be asked the following: please tell me when you symptoms started and reason for seeking care right now?

· I would then focus on location, character or quality, quantity or severity, timing, setting, aggravating or relieving factors, associated factors, and patient perception. Perception would be important as it would alert to any potential anxiety the patient may be facing. If pain is determined it would be evaluated with PQRSTU

· Past health history would be important as the patient may not know the importance of prior medical history on current health. Questions would be in regards to childhood illnesses, accidents or injuries, hospitalizations, prior operations, immunization, obstetric history, last examination date, allergies, depression, and family history. Review of systems would also be performed. This would assist to “ (1) to evaluate the past and present health state of each body system, (2) to double check in case any significant data were omitted in the present illness section, and (3) to evaluate health promotion practices” (Jarvis, 2015, p 54).

Soap

Subjective pertinent positive information includes: sleeping during the day and cannot sleep at night. This may be influenced by hormonal changes or life event changes.

Pertinent negative information: Denies other health problems, medication, or environmental allergies.

Objective information: Would be patient being 52 years old and any physical findings observed by provider. Patient may be going through hormonal changes such as menopause or be experiencing insomnia from life event. In addition provider would need to obtain vital signs and diagnostic test results.

Assessment: Discuss main symptoms, review objective and subjective data, and most likely diagnosis.

· Menopause diagnosis: Probable based on PE. Patient age and symptoms of sleep disorder.

· Insomnia diagnosis: Probable based on sleep disorder, sleeping difficulty, and would need to question for depression during assessment

Plan:

Patient education: Instruct on foods to avoid prior to going to bed such as caffeinated beverage, high-fat meals, and spicy foods. Education on having a room dark at night and bright light during the day. Attempting to sleep and awake around same time while avoiding daytime napping.

Preventative Care Education: Include routine mammograms education, vaccination recommendations, screening for tobacco use, screening for elevated blood pressure, screening for cancers education, and glucose screening (DCHR, 2021).

Treatment: Melatonin supplement

Further diagnostic evaluation: Diary to track sleep patterns. FSH, estrogen, thyroid-stimulating hormone, and CBC blood test.

Follow-up: Go to the ER if difficulty breathing or having suicidal ideation, return to clinic in 72 hours for follow up .

References:

DCHR. (2021). Adult health maintenance guidelines. Retrieved from https://dchr.dc.gov/sites/default/files/dc/sites/dchr/publication/attachments/Adult%20Health%20Maintenance%20Guidelines_dchr.pdf (Links to an external site.)

Jarvis, C. (2016). Examination and Health assessment. (7th ed.). St. Louis, Missouri: Elsevier

WednesdayMay 19 at 4:39am

Nice job overall. What does melatonin do for menopause? What dose would you prescribe?

Dr. MIlls

Collapse Subdiscussion Kelly Vasquez Garcia

Kelly Vasquez Garcia

WednesdayMay 19 at 9:02pm

Hello Dr. Mills,

Our circadian rhythm undergoes many changes especially as we age. This cyclical pattern may cause atheroscleroisis, impaired cognition, mood disturbance, and even cancer when metabolic alterations occur (Pines, 2016). Menopause is known to cause sleep disturbance with peak of hot flashes in afternoon. In specific “endogenous secretions of melatonin decrease with aging across genders, and among women, menopause is associated with a significant reduction of melatonin levels, affecting sleep” (Pines, 2016). While there is still ongoing studies and additional evidence needed to confirm melatonin exact impact on menopause I believe this is one intervention that is least invasive. The dietary supplement may assist with sleep. Prior to trying any pharmaceutical medication I believe it would be beneficial to start slow with a low dose of dietary supplement versus immediately starting patient on pharmaceutical drug. This of course would change depending on lab findings and gravity of patient diagnosis. In addition, if patient has insomnia and blood laboratory findings demonstrate otherwise healthy patient it would assist with sleep. I would need to find patients lowest dose that is effective. So for this patient I would start with 1mg 30 minutes before bedtime at night. “In general, a dose between 0.2 and 5mg is considered a safe starting dose” (Carter, 2019).I would inform patient of melatonin toxicity symptoms and to follow up in 72 hours.

Mosis thank you for your input. I would ask the patient gynecological questions such as last menstral period, sexual activity, venereal disease history, along with any questions in regards to recent traumatic life events or work schedule change that may be affecting sleep. For diagnostic test I would include hormonal test and the ones aforementioned to rule out menopause.

Respectfully,

Kelly Vasquez Garcia

References:

Carter, A. (2019). Melatonin overdose. Retrieved from https://www.healthline.com/health/melatonin-overdose (Links to an external site.)

Pines, A. (2016). Circadian rhythm and menopause. Climacteric : The Journal of the International Menopause Society, 19(6), 551–552. https://doi-org.westcoastuniversity.idm.oclc.org/10.1080/13697137.2016.1226608

WednesdayMay 19 at 7:54am

Hi Kelly,

Great post on our patient! I also thought of her diagnosis being menopause but also thought the patient could be depressed. It is important as NPs to assess all patients for mental health disorders. Universal screening for depression in all adult patients in the primary care setting, including pregnant and postpartum women, has been recommended by the U.S. Preventive Services Task Force (Park, 2019). I recently had a baby and was screened for PPD/PPA by both my ob/gyn and my daughters’ pediatrician. So I think by adding the PHQ-9 and screening the patient may or may not change your diagnosis for her. Another thing I would add is getting more labs drawn to rule out any underlying medical conditions she may not know about. Although empirical data supporting particular tests are generally scant, initial screening tests should include complete blood counts and differential blood counts, basic metabolic studies, thyroid-function tests, and levels of vitamin B and folate (Park, 2019).

Park, L. T., & Zarate, C. A., Jr (2019). Depression in the Primary Care Setting. The New England journal of medicine, 380(6), 559–568. https://doi.org/10.1056/NEJMcp1712493

WednesdayMay 19 at 11:53am

Thank you for your post, Kelly. You did a great job in describing and talking about the course of action that you would take in assessing this patient. I like that your assessment revolved around gathering biographic data, information about the patient’s health history, and questions about the review of systems. This approach is great for narrowing down what the concerns are of the patient and what diagnoses can be determined. There are a few follow ups that I would like to ask. First, would there be any other questions that you can ask the patient to determine if there is any other subjective data that would be helpful? Second, what lab and diagnostic tests would you perform or order to properly diagnose this patient? Because this patient seems to have symptoms of depression and would also be in the age range of experiencing menopause, it would be important to include tests like a complete blood count (CBC), thyroid function test, lipid profile, and liver and kidney function tests (Jewel, 2019). These specific tests would help in determining what treatment and plan would be appropriate for this patient. It is important to not only look at the main diagnosis, but also to assess other aspects of the patient in order to have a more holistic approach in caring for the patient. This includes looking at the health history, social history, housing situation, biographical data, and support system. All of these contribute to a patient’s health, and I believe you did a great job in touching on some of these points. Again, thank you for your post, and I look forward to more posts from you!

References:

Jewell, T. (2019). Menopause Tests and Diagnosis. Healthline. https://www.healthline.com/health/menopause/tests-diagnosis#exam.

Collapse Subdiscussion Rita Misakyan

Rita Misakyan

YesterdayMay 22 at 12:28pm

Hello Kelly,

Thank you for your information. You have presented in detail your SOAP. You came up with the treatment plan of melatonin for your Insomnia diagnosis. I would like to add that some research suggests that melatonin supplements might be helpful in treating sleep disorders, such as delayed sleep phase, and providing some relief from insomnia and jet lag (Mayo Clinic, 2021). Melatonin is generally safe for short-term use. Unlike with many sleep medications, with melatonin you are unlikely to become dependent, have a diminished response after repeated use. Less common melatonin side effects might include short-lasting feelings of depression, mild tremor, mild anxiety, abdominal cramps, irritability, reduced alertness, confusion or disorientation, and hypotension (Mayo Clinic, 2021).

Other than Insomina, based on the subjective and objective data would you relate that to depression as well?

Is melatonin a helpful sleep aid — and what should I know about melatonin side effects. (2021). Mayo Clinic.

https://www.mayoclinic.org/healthy-lifestyle/adult-health/expert-answers/melatonin-side-effects/faq-20057874

Collapse Subdiscussion Rita Misakyan

Rita Misakyan

TuesdayMay 18 at 2:04pm

Depression (major depressive disorder) is a common and serious medical illness that negatively affects how one feels, thinks and acts. Fortunately, it is treatable. Depression causes feelings of sadness and/or a loss of interest in activities one once enjoyed. It can lead to a variety of emotional and physical problems and can decrease the ability to function at work and at home (American Psychiatric Association, 2021).

The 52 year- old woman represents with signs of depression. Based on the subjective data that the patient mentioned such as missing days at work every week, neglecting the family, unable sleeping at night. So the subjective data is trouble sleeping at night, loss of interest in social activities. According to Mayo Clinic, for many people with depression, symptoms usually are severe enough to cause noticeable problems in day-to-day activities, such as work, school, social activities or relationships with others (Mayo Clinic, 2021). The following questions should be asked to determine depression, such as "Are your personal relationships suffering?", "Are you having difficulties with productivity at home or at work?", "Are you having trouble sleeping?", "Are you eating too much or too little?", "Have you ever felt depressed or hopeless?", Have you bothered by little interest or pleasure in doing things?”, "Are you taking any medications or vitamins?" Is anyone from your family suffered from depression"?

Before a diagnosis or treatment, a health professional should conduct a thorough diagnostic evaluation, including an interview and a physical examination (American Psychiatric Association, 2021). The patient should be advised to check her thyroid hormones to make sure these symptoms are not related to a thyroid problem. Treatment plan for treating depression will be considered psychotherapy (cognitive behavior therapy), antidepressants, Electroconvulsive therapy (ECT), Transcranial magnetic stimulation (TMS), regular exercise which helps create positive feeling and improves mood, getting enough quality sleep on a regular basis, eating a healthy diet and avoiding alcohol can also help reduce symptoms of depression.

Depresssion. (2021). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/depression/diagnosis-treatment/drc-20356013

What is Depression. (2021). American Psychiatric Association. https://www.psychiatry.org/patients-families/depression/what-is-depression (Links to an external site.)

TuesdayMay 18 at 8:45pm

The patient is a 52-year-old female present at the clinic with no recent environmental changes or health issues.

Problem Statement

Chief complaint

Subjective

· The patient has been missing days of work almost every week work.

· The patient neglects her family.

· The patient has difficulty sleeping at night (Insomnia).

· The patient sleeps during the day.

History of present illness

None.

Past medical history:

None.

Surgical history:

None.

Allergies:

None.

Objectives

I want to assess her further by observing her posture and body movements.

· Evaluating her sitting position and if she is slumped in the chair,

· The pace of her walk, and if she is dragging her feet (Jarvis, 2016).

Body movements

· Apathy,

· Slow psychomotor;

· Appropriate dressing, neat or not;

· Facial expressions mask-like or flat;

· Speech is slow, monotonous, and

· Mood and affect (Jarvis, 2016).

Pertinent positive: Disturbed sleep pattern, lack of interest in family and work. R/T depression.

Pertinent negative: Since the patient is not on any medication and negative for health issues, the mood and lack of interest cannot be induced by drugs or, for example, physical disorders such as hypothyroidism.

Differential Diagnosis

I ask her how she feels today. I observe if her mood is congruent with the occasion, place,

and topic.

I want to apply the Patient Health Questioner -2 (PHQ-2), a screening tool for depression, with two easy questions for initial diagnosis and further questions for diagnosing the severity of depression (Jarvis, 2016). My questions for the patient care over the last 14 days were if she felt sad, depressed, or hopeless and had little pleasure in performing tasks. Based on the subjective information from her responses, my diagnosis is the patient is suffering from minimal depression with a minimal score of six unless the score adds up with responding to the rest of the questions on the PHQ-2 test.

Depression definition is over two weeks of depressed mood, characterized by disturbed sleep, appetite, lack of joy, guilt, sadness, loneliness, suicide ideation, and hopelessness (Jarvis, 2016).

Treatments

Initial treatment for depression is pharmacotherapy along with psychotherapy (Rush, 2020). Several classes of antidepressants are available to treat depression. The effectiveness of different kinds of antidepressants is comparable and within their ranks (Rush, 2020). The selection of an antidepressant drug depends on safety, adverse effects, comorbid diseases, current medications, potential drug-drug interactions, cost, and patient choice—selective serotonin reuptake inhibitors (SSRIs) are preferable compared to other antidepressants (Rush, 2020). Serotonin-norepinephrine reuptake inhibitors (SNRIs), atypical antidepressants, serotonin modulators, and atypical antidepressants are other selections (Rush, 2020). Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOs) are typically not prescribed for the beginning of the treatment since they present more side effects and safety issues (Rush, 2020). Psychotherapy such as cognitive-behavioral therapy (CBT) or interpersonal psychotherapy is recommended to best treat depression (Rush, 2020). Patients with depression generally feel better after two weeks of initiation of treatment with antidepressant medications (Rush, 2020). It is best to keep the patient on the same antidepressant medication for the duration of six to twelve weeks before changing the medication (Rush, 2020). If the patient did not show any symptom relief after four to six weeks, it is best to change the anti-depression medications (Rush, 2020).

References

Jarvis, C. (2016). Examination and Health assessment. (7th ed.). Elsevier.

Rush, A., J. (2020). Unipolar major depression in adults: Choosing initial treatment. UpToDate.

https://www.uptodate.com/contents/unipolar-major-depression-in-adults-choosing-initial-treatment?

search=depression%20treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

TuesdayMay 18 at 11:40pm

Hello, Dr. Mills and class. I want to add more to my posted discussion response regarding alternative approaches for treating depression. There are additional treatments to complement pharmacotherapy and psychotherapy for mild depression cases. Treatment and management of depression can be promoted by regular physical activities, preventing the depression from becoming worse (Harvard Health Publishing, 2021). Regular physical activity can reduce anxiety. Forty-five minutes of moderate aerobic exercise three times each weak significantly affects depression improvement (Harvard Health Publishing, 2021). House projects and gardening are considered physical activities without spending time in gyms (Harvard Health Publishing, 2021). Another element in improving depression is the proper diet. Reducing refined sugar, processed and fast foods can be beneficial (Harvard Health Publishing, 2021). Replacing fruit and nuts with unhealthy sweet snacks can improve depression (Harvard Health Publishing, 2021). Expressing appreciation for any positive life experiences can enhance medial prefrontal cortex activities related to depression (Harvard Health Publishing, 2021). Social interactions decrease the risk of more severe depression. Joining a favorite club or group activity can be improving depression disorder (Harvard Health Publishing, 2021).

References

Harvard Health Publications. (2021). The no-drug approach to mild depression.

https://www.health.harvard.edu/mind-and-mood/the-no-drug-approach-to-mild-depression

Collapse Subdiscussion Rita Misakyan

Rita Misakyan

FridayMay 21 at 1:15pm

Hello Shadi,

Thank you for mentioning about treatment options for depression. Treatment with medication is an alternate option for patients suffering from depressive symptoms. There are a wide variety of pharmacotherapy options available to treat depression but selective serotonin reuptake inhibitors (SSRIs) are used most commonly because of their efficacy and relatively tolerable side effect profile. These agents increase the amount of serotonergic activity in the brain, which often leads to improvement in depressive symptoms due to the restoration of preexisting chemical imbalances (Prescott, 2017). All SSRI agents have similar efficacy in the treatment of depression, therefore choice should be based on cost, side effect profile, and clinician experience. Psychotherapy and pharmacotherapy are often used in tandem to effectively treat depression. Each treatment modality has its benefits and barriers to success.

What do you think whar are some patient barriers for psychotherapy?

Prescott, D. (2017). When Is Pharmacotherapy Initiation Beneficial in Patients With Depressive Disorders?. American journal of lifestyle medicine. 11(3), 220–222. https://doi.org/10.1177/1559827616686051

Collapse Subdiscussion Candy Uribe

Candy Uribe

TuesdayMay 18 at 9:57pm

I would ask the patient the following:

Subjective:

How long has it been when you noticed that you started neglecting your family, missing work weekly, and unable to sleep at night?

Have you had major concerns or changes in your life? Is there something that is bothering you in life?

What other symptoms do you feel during the day? Anything new?

Past medical history, hospitalizations?

Last medical examination, last dental visit?

Unintentional weight loss? Loss of appetite?

Do you drink alcohol, wine? Do any illegal drugs?

Positive information is that she denies any health problems, medication, or environmental allergies.

Pertinent negative information

Objective:

Vital signs will be taken

Order blood test such as CBC, thyroid levels, HbA1C, cholesterol levels.

Complete head to toe assessment

Assessment:

I will assess the patients problems

Make a list of the problems and try to connect the dots of what is causing her to have insomnia.

With the little information provided in the scenario, I would think it could be stress or depression.

Plan:

I will plan based on the diagnosis I came up based on the subjective information provided. If there is not enough information, I would wait to get the results from the laboratory.

I would educate the patient about lifestyle changes, doing an activity that would distract her from her daily activities that may be causing the stress. If depression is the problem I would start her on a low dose of antidepressant such as Zoloft. I would schedule a follow up visit in 2 weeks, then a month after to see how well she is tolerating the medication.

According to Bhandari, 2020 one of the many possible symptoms of depression is Insomnia. Being a woman and being in menopause increases the chance if being depressed.

Reference

Bhandari, S. (2020). Major Depression (clinical depression). https://www.webmd.com/depression/guide/major-depression

WednesdayMay 19 at 5:06am

Thank you. What screening would you want to do for the patient to support a possible dx of depression?

Thank you,

Dr. Mills

Collapse Subdiscussion Candy Uribe

Candy Uribe

YesterdayMay 22 at 9:05am

Hello Dr. Mills,

The screening tool I would use for a possible dx of depression is the Patient Questionnaire (PHQ-9). With this tool i can explore and get answers for the pts feelings, thoughts, behaviors that the patient is experiencing. It is a 9 question tools with easy direct questions that is added at the end with a score. 1- 9 points is low depressions, 10-14 points medium depression, 15-27 points is high depression. Based on the findings, i would processed with treatment. Since the patient is also having trouble sleeping i would use the insomnia severity index tool. It is a 7 question tools that assesses the sleeping problems and habits.

Reference

University of Michigan Depression Center. Self Assessment tools. https://www.depressioncenter.org/toolkit/im-looking-more-resources-1/self-assessment-tools

ThursdayMay 20 at 8:25pm

Thank you for your post, Candy. I think you did a great job with your SOAP note, and you did a great job in organizing what each section would consist of. Even though there was not much from the case study that you can draw from, you did a great job in doing a holistic approach of assessing the patient. I also like that you took into account of other factors that may affect this patient like alcohol and drug use. One question I would like to ask you is how you would conduct your head to toe assessment because this patient does not present with any physical clinical manifestations. It would be interesting to hear your approach in how you would assess this patient and what questions specifically in the assessment you would ask. There are three suggestions I would make for the head to toe assessment. First, in regards to the head, ears, eyes, nose, and throat, I would examine the patient’s mouth, tongue, teeth, and gums. Second, I would examine her skin mainly on her extremities to see if there are any signs of cutting because one diagnosis could be depression (Nelson, 2020). And third, I would make sure to assess the patient’s neurological status by asking questions of orientation and checking reflexes and coordination. Throughout the assessment process, I would recommend asking more in depth questions if there are concerns that arise while assessing specific parts of the body. And during the assessment process, it is important to speak with the patient in a manner that builds trust and rapport to ensure an in-depth assessment to be conducted. Again, great job overall with your SOAP note, and I look forward to seeing more posts from you. Thank you, Candy.

References:

Nelson, L. (2020). How to Conduct a Head-to-Toe Assessment. Nurse.org. https://nurse.org/articles/how-to-conduct-head-to-toe-assessment/.

Collapse Subdiscussion Miguel Guillermo

Miguel Guillermo

FridayMay 21 at 9:41pm

Hi Candy,

Great job on this week topic, you provided the class with a great response to this week. Given the limited information on the patient, you constructed a well organized SOAP. I like the list of questions you listed in the subjective data. I strongly believe that the subjective data is very important because the provider can obtain valuable information to develop an effective treatment plan. I would suggest to add, any possible screening for the patient. The patient is presenting with possible depression because she is missing days from work, neglecting her family, and sleeping during the day. I would also screen the patient for possible suicide. The patient actions can be early signs of suicide ideation. It is important to identify risk factors associated with suicide. Overall your SOAP will well organized.

Reference

Turecki, G., & Brent, D. A. (2016). Suicide and suicidal behaviour. Lancet (London, England), 387(10024), 1227–1239.

Collapse Subdiscussion Alexandrina Tzvetanova

Alexandrina Tzvetanova

WednesdayMay 19 at 12:11am

I would ask the client if she has lost interest in what she used to enjoy or whether she has been feeling sad or down more than usual. I would also ask her if she had any thoughts of harming herself or has a plan to harm herself or others. I would analyze her tone of voice. Is it slow and monotonous with a weak, breathy voice? I would investigate and interview her energy levels. Does she get easily fatigued, or has she had a loss of energy? How is her weight? Was there any sudden weight loss or gain? Also, I would assess her appearance. Is there a lack of concern with her appearances, such as proper grooming or good hygiene? Is her expression flat or masklike? How is her concentration? I would perform a complete mental status examination and screen for depression using the Patient Health Questionnaire -2 ( PHQ-2) (Jarvis, 2016). If her answer was several days or higher, I’ll continue with the PHQ-9 to assess the severity of depression (Jarvis, 2016). My SOAP note would look like this: Subjective: This 52-year-old, female with no remarkable past medical hx, complains that she has been “missing days of work almost every week.” Pt reports “neglecting her family” and is “sleeping during the day but cannot sleep at night.” No significant past medical history, denies chronic medical problems, no surgical history, denies alcohol, drugs, smoking, and caffeine usage. Denies recent hospitalizations. Immunizations are up to date. Denies pregnancy and breast feeding. No history of childhood illnesses. No known drug, food, or environmental allergies. Pt denies taking any prescription or over the counter medications at this time. Objective: Vital signs are as follows: 124/78mmHg, 88 bpm, 98%, RR16, 98.6F General: Alert and oriented x 3. Pt is well developed, mal-nourished, in no acute distress. Pt is not groomed but dressed appropriately for the season. Eye: PERRLA. Extraocular movements are intact, conjunctiva is clear. Sclera is non-icteric. No exudates or hemorrhages. HENT: Atraumatic. Normocephalic, no visible or palpable masses, depressions or scaring. Hearing intact. Ear canals clear and patent. TMs translucent and mobile. Oral mucosa is moist, no pharyngeal erythema or exudates, no mucosal lesions. Neck: Supple, non-tender, no jugular venous distention, no lymphadenopathy, no thyromegaly. No bruits. Respiratory: Lungs are clear to auscultation bilaterally, no wheezing or rhonchi noted. Respirations are non-labored, breath sounds are equal, symmetrical chest wall expansion. Cardiovascular: Regular rate and rhythm, no murmur, no gallop, good pulses equal in all extremities, adequate peripheral perfusion with capillary refill <3 seconds, no edema. Gastrointestinal: Soft, non-tender, non-distended, positive bowel sounds in all quadrants, no organomegaly. No hepatosplenomegaly. No hernias or palpable masses. Genitourinary: No costovertebral angle tenderness. Lymphatics: No lymphadenopathy neck, axilla, groin. Musculoskeletal: No abnormalities of gait or station. No misalignment, decreased range of motion, instability, asymmetry, crepitus, defects, swelling, tenderness or masses. No atrophy, but decreased bilateral upper and lower extremities strength noted. Integumentary: Good turgor. No rashes, unusual bruising or prominent lesions. Warm, dry, pink, and intact. Neurologic: No focal deficits, cranial nerves II-XII are grossly intact. Sensation intact. No pathologic reflexes. Deep tendon reflexes +2 in upper and lower extremities. Psychiatric: Alert, oriented x 3. Cooperative, sad mood & affect. Intact recent and long-term memory, judgement, and insight. Assessment: 1. Depression – this is new for the patient. Patient presents with depressive symptoms and normal vital signs. 2. Differential diagnosis for depression are anxiety, bipolar, sleep-related disorders like obstructive sleep apnea, thyroid disease, anemia, chronic fatigue syndrome, autoimmune disorders, vitamin B12 deficiency, and hypoglycemia (Halverson, 2020). Plan: Ordering CBC, CMP, TSH, & Vitamin B-12 levels. Prescribing Paroxetine (Paxil) 20 mg once daily for 4-8 weeks as per the American Psychiatric Association (APA) guidelines and referring to psych for further evaluation and treatment (Halverson, 2020). Follow up in a month. Insomnia, neglecting family, and missing work are all subjective and pertinent positive because it indicates a “rule in” instead of “rule out” diagnosis. In the objective section, I would also include other data from my physical assessment and the results of my screening for depression. In the assessment section, I think depression is the cause of her chief complaint of insomnia. However, I can’t be sure, which is why I included possible differential diagnoses. I plan to follow the evidence-based practice as stated by the APA to treat depression and rule out my differential diagnoses using subsequent laboratory studies, as stated in the previous section (Halverson, 2020).

References

Halverson, J.L. (2020). Depression differential diagnoses. https://emedicine.medscape.com/article/286759-differential

Jarvis, C. (2016). Physical examination & health assessment. (7th ed.). St. Louis, MO: Elsevier

WednesdayMay 19 at 5:15am

Nicely done. What diagnosis for women of this age group can present with all these symptoms or contribute to these symptoms?

Thank you,

Dr. Mills

Collapse Subdiscussion Alexandrina Tzvetanova

Alexandrina Tzvetanova

FridayMay 21 at 10:01pm

Hello Dr. Mills,

I had not considered her age group before; however, menopause can be a differential diagnosis for women in her age group. According to Khatoon & Husain (2018), the most reported symptoms of menopause were mental and physical exhaustion and joint or muscular discomfort. Furthermore, educational status has been shown to affect the perception of menopausal symptoms (Khatoon & Husain, 2018). If women are well prepared, they can cope better and access healthcare facilities to halt or slow the progression of symptoms (Khatoon & Husain 2018). Is there a standard tool for menopause screenings? How would you treat menopausal symptoms like physical exhaustion?

Reference

Khatoon, A. & Husain, S. (2018). An overview of menopausal symptoms using the menopause rating scale in a tertiary care center. Journal of Mid-Life Health, 9(3), 150–154. https://doi.org/10.4103/jmh.JMH_31_18

Collapse Subdiscussion Lashon Dorsey

Lashon Dorsey

YesterdayMay 22 at 4:24pm

Good post Alexandria, very informative and well organized!

You foster great questions to ask her, and your SOAP note is really good. Her difficulty staying asleep occurs when the sleep cycle is disrupted; this may be related to physiological factors, illness, depression, pain, or use of medications or alcohol (Dains, Baumann & Scheibel, 2016). As you eluded to in your assessment, depressive symptoms could be the cause of her sleeplessness. I also see her hormones being out of whack due to her age in life, I know at 52 you can be feeling some pre-menopausal symptoms which can also be connected to her sleep being off, and low energy. People with depression tend to have early morning awakening; whereas those with anxiety disorder have trouble falling asleep, we have been given that she sleeps during the day and up at night (Dains, Baumann & Scheibel, 2016). I agree with you that she is depressed, now what is the root of her depression?

Reference

Dains, J.E., Baumann, L.C., Scheibel, P., (2016). Advanced Health Assessment and Clinical Diagnosis in Primary Care. Retrieved From https://online.vitalsource.com/#/books/9780323277280/cfi/6/30!/4/2/4/8/2/4@0:0 (Links to an external site.)

Collapse Subdiscussion KRISTINA DINO

KRISTINA DINO

WednesdayMay 19 at 12:45am

This 52 yr. old, female with no previous past medical hx presents with complaints of daytime sleepiness and insomnia affecting her daily living.

Subjective:

CC: She states that she has been missing days of work almost every week, is neglecting her family, and she is sleeping during the day but cannot sleep at night.

PMH: Pt denies other health problems

Medications: none noted per patient

Allergies: Environmental

(Subjective questions to ask patient):

How long has this been an issue? Is this new?

Any past relevant history

Family history

Any OTC medication, herbal supplements she is taking?

Illicit drugs recently or in the past?

Alcohol intake?

Smoke?

What is her support system like?

How does she handle stress?

Patient’s access to health care services?

How is the patient’s diet? Any recent weight changes?

Objective:

Vital signs

(How the patient appears)

Physical Exam:

· Cardiovascular

· Neurological

· Psychiatric (full mental status examination- mood and affect)

· Endocrine

PHQ-9 Depression Screen score

Assessment:

Change in mental status

Most likely diagnosis #1: Depression

Plan

Testing: CBC, CMP, TSH, T3,T4, Iron, Testosterone, Estrogen

Provided with support and information related to physical activity, guided self-help, yoga, breathing exercises, massage and warm shower before bed, and healthy nutrition. Reviewed depression screen test. Referral to psychological counseling for further evaluation. Will check blood work and follow up with patient within one week.

Differential diagnosis:

Menopause

Hypothyroidism

Anemia (for fatigue and sleepiness during the day)

Pertinent positives: Feelings of low self-esteem or worthlessness, loss of ability to function, sleeping all day, unable to sleep at night, disturbed daily activities, feelings of isolation, fatigue, positive for PHQ-9 depression scores (Maurer et. al., 2018).

Pertinent negatives: Denies palpitations, nausea/vomiting, SOB, chest tightness, suicidal plan, alcohol use, drug use

Maurer, D.M., Raymond, T.J., & Davis, B.N. (2018). Depression: Screening and Diagnosis. AM Fam Physician. 98(8),p.508-515. https://www.aafp.org/afp/2018/1015/p508.html

Collapse Subdiscussion Edwin Tobbee Jr Arceo

Edwin Tobbee Jr Arceo

WednesdayMay 19 at 1:52am

According to Jarvis (2016), it is necessary to perform full mental status examination if there’s abnormality that affects behavior which can include presence of anxiety disorder or depression, and changes with social interaction and sleep habits. The patient in the case is exhibiting signs and symptoms of depression, sleeping disorder, and stress that causes dysfunction. The patient can be screened by using the Patient Health Questionnaire-9 (PHQ-9) to assess for depression (Anxiety & Depression Association of America, 2021). Patient can be asked if patient has little interest or pleasure in doing things, feeling down, depressed, or hopeless, trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy, poor appetite or overeating, feeling bad about self, trouble concentrating on things, moving or speaking so slowly, and thoughts of being better off dead. During physical exam, patient would benefit in assessing the appearance, behavior, cognition, and thought process (Jarvis, 2016). Laboratory testing may include blood tests to check for anemia, thyroid or possibly other hormones to differentiate the diagnosis. Blood tests may also include calcium level and vitamin D levels (Casarella, 2020).

SOAP DOCUMENTATION:

Past Medical History: None

Surgical History: None

Family History: None

Medications: None

Allergies: None

ROS:

Pertinent Positive: sleeping during day but cannot sleep at night, feel that she is neglecting her family, been missing days at work

Pertinent Negative: denies health problems, medication, or environmental allergies

Appearance

Behavior

Cognitive Function

Thought Process

A/P:

Diagnosis: Depression- this is new for the patient. Will start with low dose of anti-depressant with combination of psychotherapy once a week. Educated with side effects of fluoxetine to include bleeding risk, hypersensitivity reactions, hyponatremia, sexual dysfunction, and suicidal thinking and behavior (Rush, 2020). Diagnostic testing after one week to monitor renal and hepatic function. Patient verbalized understanding and agreed with treatment plan. Will start with fluoxetine 20mg by mouth in the morning, and psychotherapy once a week. Will order CMP once a week.

Differential Diagnosis: Sleeping disorder, thyroid problem, anemia

References:

Anxiety & Depression Association of America. (2021). Screening for depression. Retrieved from https://adaa.org/living-with-anxiety/ask-and-learn/screenings/screening-depression (Links to an external site.)

Casarella, J. (2020). Tests used to diagnose depression. Retrieved from https://www.webmd.com/depression/guide/depression-tests (Links to an external site.)

Jarvis, C. (2016). Physical Examination and Health Assessment (7th ed.). Elsevier

Rush, A. (2020). Unipolar major depression in adults: Choosing initial treatment. Retrieved from https://www.uptodate.com/contents/unipolar-major-depression-in-adults-choosing-initial-treatment?search=depression&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 (Links to an external site.)

Collapse Subdiscussion Lashon Dorsey

Lashon Dorsey

WednesdayMay 19 at 9:19am

I would ask how long has she been feeling this way, any night sweats? Has there been major

events that has happened to her in the last 3 to 6 months? How has her diet been, what has she

been fueling her body with nutritionally? Discuss if she has history of surgeries and any history

or current health problems on her paternal and maternal side. I would do a head to toe assessment

and vital signs. Further tests would include: CBC, would show if she has any anemias or

infections, Serum electrolytes; symptoms of depression can be exacerbated by hyponatremia,

hypernatremia, hypercalcemia, and hyperphosphatemia (Dains, Baumann & Scheibel, 2016).

Thyroid function test would be ordered as well an elevated level of thyroid-stimulating hormone

(TSH) is related to chronic symptoms of depression. A hyperthyroid state can be associated with

anxiety. I would also ask for a urine toxicology just to cover all bases such as drug intoxication

as a cause of psychological symptoms (Dains, Baumann & Scheibel, 2016).

S: patient states missing days of work almost every week, sleeping during the day, reports neglecting family, and unable to sleep at night (pertinent positive) Medical history: denies health problems. Allergies: NKA

O: appears to be tired just by evaluating her body language and facial expression. She is also worried about missing work, and not being there for her family. She appears to be dressed well and her hygiene is intact. Lungs are clear, vital signs are with in normal limits. She is alert, and aware of stimuli from the environment and within the self and responds appropriately and reasonably soon to stimuli (Jarvis, 2016 ), the quality and pace of speech is rich, moderately slow and clear. She denies any pain (pertinent negative). She has 2 children and newly divorced. She has not had a consistent menstrual in two months. (DX)Appears maybe in the preliminary stages of peri-menopause with some components of depression due to some stated stress factors in her life.

A: Labs are ordered for further assessment. Patient risk factors: possible spiraling into depression and compromising family and job. Other health concerns: hormonal imbalance that is impacting her overall wellbeing. Screening for depression, she appears to her moderate to highly depressive

P: An initial treatment plan may be for an initial trial of treatment over a short interval with a re-assessment and further treatment planning at that later time (CHP, 2015). Labs will be evaluated. Gave information on Menopause, depression. Will connect her with a social worker/counselor. Offered some suggestions for over the counter sleep aides. Developed a plan for her wellness, starting with some form of movement/exercise, eating regime changes. Will reevaluate and see her back in the office in a week to discuss lab results and re-assessment of treatment plan.

References

CHP, (2015) Best Practice: The Anatomy of a Soap Note. Retrieved From https://www.chpgroup.com/evidence-in-ih/best-practices-the-anatomy-of-a-soap-note/ (Links to an external site.)

Jarvis, C., (2016). Physical Examination Health Assessment. Retrieved From https://online.vitalsource.com/#/books/9781455728107/cfi/6/10!/4/2/12@0:97.3

Collapse Subdiscussion Edwin Tobbee Jr Arceo

Edwin Tobbee Jr Arceo

YesterdayMay 22 at 11:21pm

Thank you Lashon for an in-depth analysis of the case. As you have mentioned, it is essential for an advanced practice nurse to complete an extensive health assessment in order to obtain an accurate picture of the patient that would lead to an accurate assessment. It is true that thyroid condition could lead to signs and symptoms of depression, and insomnia. According to Singh (2021), when thyroid produces too little or too much thyroid hormone, it throws off body’s metabolism, which can affect sleep. Too much hormone production causes an overactive thyroid, or hypothyroidism. This can lead to anxiety, rapid heart rate and insomnia (Singh, 2021). If the TSH level comes back abnormal, would you treat your patient differently? Since the patient is suffering from insomnia, and sleep disorder, I would also recommend a sleep diary or sleep study test. Differential diagnosis for insomnia may include hyperthyroidism, sleep apnea, restless leg syndrome, anxiety, diabetes, COPD, CHF, depression, and PTSD (Singh, 2021).

Reference:

Singh, A. (2021). Thyroid issues and sleep. Retrieved from https://www.sleepfoundation.org/physical-health/thyroid-issues-and-sleep

Collapse Subdiscussion Shiela Ng

Shiela Ng

WednesdayMay 19 at 11:37am

Hello Dr. Mills,

Subjective: Chief complaints: "Not able to sleep at night, been missing days of work every week"

HPI: A 52- year old female came in with chief complaints of missing days if work every week,no getting sleep at night but sleep during the day. She said she is neglecting her family. Patient denies any other medical health problems, denies taking any medications.

How long have you been missing your days work?

Are you or your family going through a problem or a crisis?

Are you on a sleeping medications? How do you take it?

Past medical history: none

Surgical history: Did you have any surgery in the past?

Family history: Is there any in the family member has history of hypertension , diabetes, depression, anxiety?

Medications: none

Social history: Do you smoke or have you smoke in the past?

Do you drink alcohol or any forms of liquor?

Do you use any recreational drugs?

Are you married?

What type of work do you do?

Are you on any forms of contraceptive?

Are you sexually active?

Allergies: no drug allergies but with environmental allergies

Immunizations: Are your vaccines up to date?

Reproductive: When was your last menstrual period?

Preventative care: when was your last Pap test?

Objective:

Check Vitals signs , Height and Weight, Body Mass Index

Review of Systems:

General appearance: A 52-year-old female who is alert and oriented x3, well nourished and well developed, and not in distress. Patient is well dressed appropriately for the season

Eyes: Pupils are round and reactive to light. Conjunctiva is clear and is non-icteric

HENT: head is normocephalic, no mass palpated . Ear canals are clear and patent. Nasal passages are clear. Oral mucosa is moist and intact. no enlargement of tonsils noted.

Respiratory: Assess for lung sounds, no wheezing or rhonchi noted.

Cardiovascular: Regular rate and rhythm, no murmurs or gallop. No edema to bilateral upper and lower extremities. Cap refill is < 3seconds.

Gastrointestinal: Abdomen is soft, non tender, not distended. Bowel sounds present to all quadrants

Genitourinary: no costovertebral angle tenderness noted

Musculoskeletal : no decreased of range of motion noted, gait is normal.

Integumentary: skin is warm ,intact with good turgor. No lesions or rashes noted.

Neurologic: Cranial nerves II -XII are intact. Deep tendon reflexes are 2+ to both upper and lower extremities

Psychiatry : patient is alert and oriented x3, pleasant, calm and cooperative.

Labs and Diagnostics tests: TSH- if hyperthyroidism is suspected ,insomnia can be present

Urine Drug screen- to check if patient is on any form or controlled substances.

Assessment and Plan:

Patient might me suffering from insomnia based from not getting enough sleep at night, skipping work and not able to take care of her family. We will identify underlying medical conditions, such as depression or anxiety. We will look into the cause of poor sleeping habits. Encourage patient to do some exercise an hour before night of sleep. Educated on sleep hygiene, which involve developing habits conducive to sleep, such as maintaining regular bedtimes and rise times, avoiding daytime naps, avoiding alcohol before bedtime, and avoiding caffeine. Hypnotics can be recommended if non pharmacologic measures did not work (Epocrates). Refer to behavioral or cognitive therapist to help the patient recognize the negative or unhelpful thought or behavior patterns contributing to sleep disturbance.

Hypnotics:

Ambien 5-10mg orally at bedtime . Educated on side effects such as drowsiness, lethargy, headache, in rare cases sleep walking can happen, anaphylactic reactions, if these happen ,let doctor know.

Follow up care: to see primary care physician in 2-4 weeks to check if treatment options are working or need to modify.Patient agreed to treatment and plan.

Reference:

Epocrates (n.d.) Insomnia. https://online.epocrates.com/diseases/22744/Insomnia/Prevention

ThursdayMay 20 at 7:30pm

Nice job overall. Where should Review of Systems go?

Thank you,

Dr. Mills

Collapse Subdiscussion Shiela Ng

Shiela Ng

FridayMay 21 at 12:51pm

Hello Dr. Mills,

Review of systems should go under Objective as these findings are seen by the health care provider which are measureable and are obtained using five senses or direct observation.

Collapse Subdiscussion Diana Akhverdyan

Diana Akhverdyan

WednesdayMay 19 at 4:34pm

This 52-year-old female with a past medical history of none stated or known presents with a chief complaint of increased drowsiness throughout the day and insomnia at night and new onset of feeling a sense of neglect towards her family.

Questions to ask the patient:

When did you first notice the symptoms?

Have you had suicidal thoughts or ideations?

What do you think contributes to the symptoms?

Is there anything that makes the symptoms worse or better?

Are there other symptoms that you experience?

Do you use alcohol or other recreational drugs? If so, how often?

How is the condition at home and work?

Has anyone in your family been diagnosed with depression in the past?

Physical Exam Elements:

Vital Signs

Patient's appearance like body posture, hygiene, and body movement.

Patient's behavior such as speech, consciousness, and articulation.

Further Testing

Total blood count- this would be effective in ruling out the possibility of a mental disorder that might be causing the patient's symptoms.

Thyroid-stimulating hormone (TSH) test- a TSH test to measure the thyroid hormone which is responsible for the regulation of mood levels.

Pertinent Positive: Patient reports missing days of work almost every week, neglecting family, sleeping during the day, and unable to sleep at night.

Pertinent Negatives: No other medical conditions

Diagnosis: Depression

Differential diagnosis: Hypothyroidism

Treatment plan

One of the treatment interventions would be the use of Selective serotonin reuptake inhibitors (SSRIs), such as Paroxetine. SSRIs are effective in relieving stress symptoms. Another treatment intervention would be psychotherapy. Psychotherapy would involve getting the patient to talk about the issues they face with a mental health practitioner (Putnam et.al, 2017). Talking about issues that affect the patient will help in reducing stress in the patient.

Health Education and Lifestyle Changes

Take medications as prescribed

Exercise regularly

Eat healthy such as fruits and vegetables

Manage stress effectively

Follow-up: once monthly

Reference

Putnam, K. T., Wilcox, M., Robertson-Blackmore, E., Sharkey, K., Bergink, V., Munk-Olsen, T., ... & Causes, A. T. (2017). Clinical phenotypes of perinatal depression and time of symptom onset: analysis of data from an international consortium. The Lancet Psychiatry, 4(6), 477-485.

WednesdayMay 19 at 5:56pm

Diana,

Great post! Since your differential diagnosis is hypothyroidism, I would add the following questions:

Have you had any weight gain or loss?

Have you had any increased sensitivity to hot or cold temperatures?

Any changes to bowel movement?

Are there any menstrual irregularities?

Thyroid disease can affect your mood and primarily cause anxiety or depression so I would agree that it is a great differential diagnosis.

WednesdayMay 19 at 6:02pm

Mayo Clinic. 2021. Thyroid disease: How does it affect your mood?. [online] Available at: <https://www.mayoclinic.org/diseases-conditions/hyperthyroidism/expert-answers/thyroid-disease/faq-20058228> [Accessed 20 May 2021].

WednesdayMay 19 at 5:46pm

Problem Statement- A 52-year-old woman complains that she has been missing days of work almost every week, she states she is neglecting her family, and she is sleeping during the day but cannot sleep at night. She denies other health problems, medication, or environmental allergies.

Subjective- “She states she is neglecting her family”. “She is sleeping during the day but cannot sleep at night”.

PMH- No significant PMH

Family Hx-

Mother Hypertension

Father- Major Depression

Social Hx- Married, has two sons, works as an accountant, exercises occasionally, drinks socially, does not smoke.

ROS- Decreased appetite in the past 3 weeks associated with weight loss.

In this portion of the interview, I want to know the following information:

When did you start feeling this way? How long have you been feeling this way? Have there been any recent trauma in your life? Do you feel you have a support system at home? How is your appetite? Have you had recent weight loss? Do you have any suicidal thoughts?

Objective-

Vital Signs: BP 126/64 Pulse 96, Respiration 12, Saturation 98% on RA.

General: Patient Alert and Oriented x 3, Patient is well developed, well-nourished, in no acute distress. Affect appears normal, appears disheveled. Abnormal posture (patient is sitting in the exam table hunch over and seems tense). She exhibits speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are intact There are no apparent signs of hallucinations and delusions. Associations are intact, thinking is logical, and thought content appears appropriate. Suicidal ideation is denied, and homicidal ideation are also denied. No signs of withdrawal or intoxication are evident.

Pertinent positives- Depressed mood, lack of energy and interest, disturbed sleep schedule.

Pertinent negatives- No hallucinations or delusions, no suicidal ideation or homicidal ideation, logical and coherent thinking.

Assessment- Body posture and attitude convey an underlying depressed mood. Facial expression and general demeanor reveal depressed mood.

Diagnosis- Acute Depression

Differential Diagnosis- Anxiety

Plan- I will start this patient on Fluoxetine 20mg once a day, fluoxetine is the safest because it has a short half life and tapering down will be easier. I will recommend diversional activities that will assist her with coping with stress. I will follow up with the patient in two weeks to evaluate the treatment plan. Before the initiation of treatment I will get CBC and BMP to have a baseline to compare.

Jarvis, C. Physical Examination and Health Assessment. [VitalSource Bookshelf]. Retrieved from https://online.vitalsource.com/#/books/9781455728107/ (Links to an external site.)

Williams & Wilkins, l. (2014). Nursing 2014 Drug Handbook (34th ed., p. 1339). Wolters Klumer.

Collapse Subdiscussion Shiela Ng

Shiela Ng

FridayMay 21 at 12:55pm

Hello Herminia,

This is an informative post. Based on the patient's signs and symptoms patient might be experiencing depression. Insomia was one of the symptoms, are you also going to use Hamilton Rating Scale for depression to confirm what patient is going through?

YesterdayMay 22 at 4:08pm

Sheila,

Thank you for your comments and your suggestion of the Hamilton Rating Scale. I believe that using this scale is a good way to measuring progress of the symptoms. The scale is separated by different categories and measuring things like insomnia, mood, weight and guilt feelings amongst others things. What I mostly like about this is that there is a pre treatment, 1st follow up and 2nd follow up.

Collapse Subdiscussion KRISTINA DINO

KRISTINA DINO

YesterdayMay 22 at 2:57pm

Hi Herminia,

Great explanation. I also suspect acute depression in this patient. Some main symptoms of acute depression include trouble sleeping, persistent thoughts of self harm, loss of interest in people and activities, fatigue, mental confusion, sadness and anger (PULSETMS, 2021). It's important to ask detailed questions about why the patient has been experiencing the symptoms she is feeling and also for the length of time. Depression is also linked with increased risk of heart problems and studies have shown that those patients are at risk for stroke and heart attacks. Because of this, we may want to also do labwork of CBC, CMP, etc to check our patient's health and see if we need to supplement or prescribe any medications to help prevent other medical problems.

PULSETMS. (2021). Understanding the signs of acute depression. https://pulsetms.com/depression/acute-effects/

Collapse Subdiscussion Kandi Zielinski

Kandi Zielinski

WednesdayMay 19 at 7:12pm

Collapse Subdiscussion Johana Cordova

Johana Cordova

WednesdayMay 19 at 8:47pm

Physical Examination and Health Assessment

In this case study, availability of another person in the history taking process is crucial. Most importantly, a close person include an individual who witnessed the patient's behavior changes during the onset of symptoms. However I would ask the patient the following questions to help reach a diagnosis.

· I will ask for the patient's name, day of the week, and whether she knows where she is. This is to check for awareness of time, place, and person (Dains et al., 2018).

· When did the symptoms begin? This helps to assess the disease's progress.

· Does she have any history of drug or alcohol use? If so, what was or is the extent of drug use?

· Have you recently been, or previously involved in an accident? This is to check for head trauma.

· Tell me about your diet.

· Do you know of any person in your family who has presented with similar symptoms?

· What do you love doing in your spare time? Are you still doing these activities?

· Have you had any suicidal thoughts?

· Have you lost anyone recently?

Physical exam

In this section, I will check for vital signs, do a mental, neurologic, and abdominal exam (Dains et al., 2018). I will also evaluate the respiratory and cardiovascular systems.

Lab and tests

· Blood chemistry.

· A thyroid function test.

· Serum B12 and foliate.

· A CT scan.

Pertinent positive information

16. Subjective

. Missing days of work.

. Neglecting family.

. Sleeping during the day.

. Sleeplessness at night.

Pertinent negative information

16. Subjective

. Denies other health problems.

. Denies medication.

. Denies environmental allergies.

Assessment

Diagnosis: Depression.

Differential diagnoses: Dementia, hyperthyroidism, hypothyroidism.

Plan

16. Trazodone 150mg. I tablet, 2 times a day. Every 12 hours. For A month (Khouzam, 2017).

16. Omega fatty acids supplements.

16. Patient should keep a journal. Write every positive thing that happened to her each day.

16. Daily physical exercise. Jogging.

16. Eat a well-balanced diet.

16. Daily interaction with family.

16. Follow up in three weeks.

References

Dains, J. E., Baumann, L. C., & Scheibel, P. (2018). Advanced Health Assessment & Clinical Diagnosis in Primary Care E-Book. Elsevier Health Sciences.

Khouzam, H. R. (2017). A review of trazodone use in psychiatric and medical conditions. Postgraduate medicine, 129(1), 140-148.

Collapse Subdiscussion Elin Minassian

Elin Minassian

WednesdayMay 19 at 9:11pm

Depression is a medical condition that causes feelings of despair as well as a lack of interest in activities of daily living. Depression affects a person's behavior, thinking, and feelings. Many physical and emotional issues may arise as a result of depression and it has an effect on an individual's day-to-day activities. With the information provided for this 52-year-old patient I would begin by first asking the following questions:

Questions to ask the patient to collect further data:

. How long has this been going on?

. What hours do you work? How many days per week? How much are you missing work?

. Are there any changes you have noticed that may contribute to this situation?

. Is there anything that makes it worse? Better?

. Are there any other symptoms you are noticing besides sleeping during the day and not at night?

. Are there unresolved issues at home?

. Are you taking any recreational drugs or OTC medications?

. After collecting my data for the subjective data I would continue to observe and obtain the objective data being the physical exam elements:

Physical exam:

. Patient's overall demeanor, body language, expression, and posture

. Mood and affect

. Level of consciousness, vitals

. Hygiene, dress, and grooming

Labs & diagnostics:

. Lab test which involves, serum electrolytes, a complete blood count and testing of the thyroid to confirm it is working well.

. Conduction of a psychiatric evaluation will be done as well.

Pertinent positive information:

. Missing work

. Neglecting family

. Day sleeping

. Not sleeping at night

Pertinent negatives:

. Denies other health problems as well as allergies and other medications

Differential diagnosis:

Insomnia

Working diagnosis:

Depression

Treatment plan

The patient will benefit from medication and psychotherapy. Citalopram would be my drug of choice. A selective serotonin reuptake inhibitor, such as citalopram, is an example of an SSRI I would prescribe. The SSRI is thought to be safe and has less side effects than other antidepressants. Psychotherapy is the process of addressing a patient's illness by consulting with a mental health professional about their problems (LeMoult & Gotlib, 2019). The health education that I will give to the patients will emphasize the importance of taking the medication as prescribed, learning more about depression and its symptoms, paying attention to depression causes, and avoiding recreational drugs and alcohol. After one month, the patient can return to the hospital for a check-up.

Reference

LeMoult, J., & Gotlib, I. H. (2019). Depression: A cognitive perspective. Clinical Psychology Review, 69, 51-66.

Collapse Subdiscussion Shana Matatov

Shana Matatov

WednesdayMay 19 at 9:44pm

This 52-year-old woman’s complaints can be a cause for concern. Sleep disturbance, neglecting the family, and missing work can be caused by numerous different factors. The patient denies any health issues or medication use. Many different screenings can be completed for this patient, but I would specifically screen for depression and anxiety (Dains et al., 2015). Additionally, it is important to screen patients for illness and medication use (even if they deny it), substance abuse, mental illness or family history of mental illness, and general appearance (Dains et al., 2015).

Questions to ask the patient:

18. Do you ever feel like harming yourself or others?

18. Are you currently experiencing any life stress?

Subjective Data:

. Neglecting family

. Missing work

. Sleeping during the day

. Awake at night

Objective Data:

. 52-years-old

. No allergies to medications

. No environmental allergies

Differential Diagnosis: The patient may be experiencing a major depression disorder, as she is uninterested in family and work (Dains et al., 2015). Additionally, she is experiencing sleep disorders which are significant signs and symptoms of major depressive disorder (Dains et al., 2015).

Assessment:

As the patient’s provider, I will complete a comprehensive assessment of the patient. Such assessment would be including gathering information such as vital signs, appearance, behavior, speech, and skin assessment (Mayo Clinic, 2018). The patient should undergo a psychiatric evaluation. Additionally, I would order laboratory tests such as CBC, electrolytes, thyroid tests, toxicology, folate, and vitamin B 12 (Dains et al., 2015).

Treatment:

There are several treatments a patient with major depressive disorder can undergo. Medications such as anti-depressants are one option, but other non-pharmacological options are available and, in many cases, can be tried first (Mayo Clinic, 2018). In addition to medication, treatment options include therapy, psychotherapy, identifying triggers, avoiding alcohol and other substances, physical activity, healthy eating, electroconvulsive therapy, mediation, acupuncture, music therapy, journaling, and transcranial magnetic stimulation (Mayo Clinic, 2018).

References

Dains, J. E., Baumann, L. C., & Scheibel, P. (2015). Advanced health assessment and clinical diagnosis in primary care (5th ed.). Mosby.

Mayo Clinic. (2018, February 3). Depression (major depressive disorder). https://www.mayoclinic.org/diseases-conditions/depression/diagnosis-treatment/drc-20356013

Collapse Subdiscussion Osaigiakpe Ugheighele

Osaigiakpe Ugheighele

ThursdayMay 20 at 12:23am

This patient could be suffering from possible anxiety or depression since she is missing work for no reason, neglecting her family and not sleeping at night. Some questions I would ask her will be “In the past two weeks, how often have you felt down, depressed, or hopeless?” depending on her answer, this is a sign of depression if she answered “yes”. Another question will be “Have you had any thoughts of suicide (Links to an external site.) ?” “How is your energy?” Declines in energy level are a common sign of depression (Links to an external site.) . “Do you prefer to stay at home rather than going out and doing new things?” this can be isolation, since she is neglecting her family, it could be she is isolating herself from her family. I would also ask her if she has had any traumatic experience recently like loss of loved one. I will defiantly give her a PHQ-9 to fill out which is a depression screening questionnaire that has more questions. Other testing, I would do will be to check her hormones levels. Hormones are chemical messengers that can have a powerful influence on the brain and someone’s mental well-being. When hormone levels are balanced, a person tend to have stable moods and feel energetic, motivated, and mentally sharp. When hormone levels are out of control, a person may experience symptoms that are associated with psychiatric illnesses, such as depression (Hage & Azar, 2012).

Problem statement (chief complaint): A 52-year-old woman complains that she has been missing days of work almost every week, she states she is neglecting her family, and she is sleeping during the day but cannot sleep at night.

Subjective (history): Patient reports missing work almost every week, sleeping during the day and unable to sleep at night. She said she has been neglecting her family. Patient denies past medical history and family history. Patient denies having any allergies.

Objective (physical exam/diagnostics): Vital signs, 53yo female alert and oriented x4 and able to answer questions appropriately. Patient’s pupils are round and reactive. Head, ear, Nose and throat appears appropriate for patients age, No JVD noted on her neck, resp are unlabored on room air, heart sounds regular, pulses are presents and regular, abdomen is soft and non-distended, bowel sounds present in all quadrant, no abdominal pain reported, no gait issues, patient is able to walk independently, skin is intact . No labs to review today.

Assessment (diagnosis) and plan: Depression. Patients complain of not being able to go to work and sleep at night, she has been neglecting her family and has been staying indoors by herself. Patient is negative for depression per PHQ-9 answers. Vital signs are stable and physical exams appears within normal limits. Will refer patient to consult with Psychiatrist, laboratory work ordered to check hormones level. Advised patient to take OTC melatonin and to follow up with psychiatrist. Advised patient to seek immediate help if symptoms become worse or is she has suicidal ideal. Patient agrees with plan.

References

Hage, M. P., & Azar, S. T. (2012). The Link between Thyroid Function and Depression. Journal of Thyroid Research, 2012, 590648-590648. Retrieved 5 20, 2021, from https://ncbi.nlm.nih.gov/pmc/articles/pmc3246784

Collapse Subdiscussion Diana Akhverdyan

Diana Akhverdyan

FridayMay 21 at 9:51am

Osaigiakpe,

Thank you for the informative post. The questions you would ask in a physical assessment for a patient with possible depression are in my opinion very accurate. The next question you would need to ask a patient depends on their previous answer. To rule out other conditions that may cause similar symptoms, a medical examination is needed. I would like to elaborate that a medical history helps to identify the true source of the problems. Major Depressive Disorder has long been considered a mood disorder (Gulf Bend, 2016). The word mood refers to a person's emotional state or temperature. It's a set of emotions that convey emotional ease or discomfort. Mood is often described as an ongoing or prolonged emotion that colors a person's entire life and state of well-being. When you stated you would ask about past trauma, reflecting on possible PTSD due to past drama would directly correlate when reflecting from the patient’s past. In your assessment and diagnosis plan for the patient it is critical to involve teachings in regards to the OTC melatonin, as there are side effects that may affect mood and behavior.

Reference:

Gulf Bend MHMR Center. (2016, July). https://www.gulfbend.org/poc/view_doc.php?type=doc&id=60749&cn=5.

Collapse Subdiscussion Miguel Guillermo

Miguel Guillermo

ThursdayMay 20 at 1:04pm

HPI: 52 year old patient reports missing days of work almost every week, sleeps during the day but awake at night, and neglecting family. This would be considered pertinent positive because it is what the patient is feeling. It would support the patient diagnosis.

Past Medical History: Denies any other health problems

Allergies: KDA

Medications: Not taking medications

Vital Signs: vital signs measure the body’s basic functions. Vitals display a snapshot of what’s going on inside the body. They provide crucial information about the organs. Based on the results, a provider may conduct further tests, diagnose a problem, or suggest lifestyle changes. The most common vitals checked are body temperature, blood pressure, heart rate, respiration, and pain.

Physical Assessment: The physical assessment is a valuable tool nurse practitioners have in their arsenal of skills. A thorough and skilled assessment allows the nurse practitioner to obtain descriptions about the patient’s symptoms, how the symptoms developed, and a process to discover any associated physical findings that will aid in the development of differential diagnoses. Assessment uses both subjective and objective data. Subjective assessment factors are those that are reported by the patient. Objective assessment data includes that which is observable and measurable. Along with the description of patient’s appearance which includes posture, body movements, dress, grooming and hygiene. Behavior will include level of consciousness, facial expression, speech, pace of conversation, articulation, and word choice. Mood and affect can be evaluated by patient’s body language

Labs/Diagnostic Studies: Knowing the different normal lab values is an important step in making an informed clinical decision as a nurse (Links to an external site.) . Diagnostic and laboratory tests are tools that provide invaluable insights and information about the patient. Lab tests are used to help confirm a diagnosis, monitor an illness, and the patient’s response to treatment.

A/P: Patient should be screen for possible depression. Patient is expressing that she is having a difficult time sleeping at night since she is sleeping during the day. Patient also is missing days at work, which can jeopardize her employment status with her employer. Patient is neglecting her family which shows that she might not have support from her family. The medication I would recommend is Melatonin 5mg to be taking at night before going to sleep. Also educate the patient on ways to stay awake during the day. I would also refer the patient to a psych consultation. The patient would benefit from a psych evaluation to have a better understanding why the patient is feeling that way.

Reference

Lenert L. A. (2017). Toward Medical Documentation That Enhances Situational Awareness Learning. AMIA ... Annual Symposium proceedings. AMIA Symposium, 2016, 763–771.

Collapse Subdiscussion Diana Akhverdyan

Diana Akhverdyan

ThursdayMay 20 at 4:44pm

Miguel,

Your post regarding this patient throughout a physical assessment was highly informative. I would like to further address the issue in a primary care setting, major depression is a significant health entity. Despite the fact that major depression is common in primary care, it is often misdiagnosed and untreated. The prevalence of major depression in chronically ill patients increases morbidity, mortality, and medical resource use (Rouchell, 2010). Depression can be the first symptom of a medical problem. In primary care, a comprehensive work-up is needed to diagnose major depression. The best treatment for this depressive condition is a combination of therapy and antidepressant medicine. There are many signs and symptoms that I would like to suggest in order to diagnose depression. Depression in many of these patients is missed and goes untreated. Bad self-esteem, hopelessness, helplessness, suicidal ideation, brooding pessimism, tearfulness, depressed appearance, social isolation, and loss of emotional reactivity are all clinical signs of depression that can be prevented if the clinician searches for them (Rouchell, 2010). I would like to add that counseling a depressed patient necessitates a thorough examination of the presenting issue, an investigation of the precipitating incidents, and adaptable psychosocial treatments.

Reference:

Rouchell, A. M. (2010, April 2). Major depression in primary care. The Ochsner journal. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3117543/.

ThursdayMay 20 at 7:31pm

Nice job! What screening tool would you use for Depression?

Thank you,

Dr. Mills

Collapse Subdiscussion ana lorina Abejaron

ana lorina Abejaron

FridayMay 21 at 3:05pm

Questions to ask patients:

. What kind of job do you have?

. What time do you start and end your work?

. How stressful is your job? If you get stress or overwhelmed at work, what do you do to address that?

. How many hours of sleep do you at night? Do you use any medications or routine that helps you sleep at night? Are you having trouble falling asleep, staying asleep, or you’re waking up frequently?

. What makes you think you are neglecting your family?

. Any feelings and symptoms of hopelessness?

. How is your appetite? Did you have any recent weight loss?

. Do you have any other symptoms such as, shortness of breath, palpitations, and chest pain?

. Do you have any problem home?

Physical exam:

. Check Vital Signs

. Perform Patient health questionnaire- 9(PHQ-9).

Further testing:

. Perform laboratory testing such as CBC, TSH, T4, T3, calcium and vitamin D levels.

. Psychologist evaluation referral

S: Patient states that she is missing days of work almost every week, she sleeps mostly during the day and cannot sleep at night, she also mentioned that she is neglecting her family.

O: Patient’s behavior, mood, and affect during the visit, Patient’s appearance, grooming, hygiene, and body movement.

A: Diagnosis: Depression

Patient complains that she has been missing work, she sleeps mostly on the days, and feels like she is neglecting her family. Those statement can be an indication that patient is experiencing depression. Depression is a mood disorder with the manifestation of persistent feeling of sadness and loss of interest that followed by somatic and cognitive changes that significantly affect the individual’s capacity to function… the depressive symptoms initially start with neurovegetative symptoms that includes changes in sleeping patterns, appetite, and energy level (Chand & Arif, 2020).

P: The plan for this case scenario is to perform laboratory testing such as Perform laboratory testing such as CBC, TSH, T4, T3, calcium and vitamin D levels. Also, psychologist referral for evaluation. Moreover, since patient is presenting with depressive symptoms for weeks now, patient can be prescribed a medication to manage depression. One of the medications that can be given is called selective serotonin reuptake inhibitors (SSRIs) such as citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, vilazodone, and vortioxetine. SSRIs is commonly used as a first-line pharmacotherapy for depression. The action of this medication is to inhibit the reuptake of serotonin and making it more available (Chu & Wadhwa, 2020). In addition, lifestyle changes can also encourage by promoting healthy lifestyle that includes, a well balance diet, increase physical activities and exercise, reduction of stress and consider holistic approach by doing yoga, meditation, acupuncture, and relaxation therapy.

References

Chand, S. P. & Arif, H. (2020). Depression. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK430847/

Chu, A. & Wadhwa, R. (2020). Selective serotonin reuptake inhibitors. Retrieved https://www.ncbi.nlm.nih.gov/books/NBK554406/#:~:text=Selective%20serotonin%20reuptake%20inhibitors%20(SSRIs,safety%2C%20efficacy%2C%20and%20tolerability.

FridayMay 21 at 7:06pm

Hello, Dr. Mills. Here is my revised discussion prompt.

History

The patient is a fifty-two-year-old female with a recent disturbed sleeping pattern. She states she misses working days almost weekly. She sleeps throughout the day and is not able to sleep during the night. She also mentions that she neglects her family. She denies any allergies, medical health problems, or taking any medications.

Then I will go through COLD CARTS questions.

I will ask her about the exact onset time of her sleep problems, missing work, and emotional issues with her family members. Then I will proceed to ask her If her sleep issues have any related factors such as a new environment to a new bed. Also, I would like to know how many hours a night she is awake and how we hours a day her sleep lasts. I will ask her how the rest and emotional changes feel to her. If she is feeling sad or she is in pain. If she has any pain, where is it located? Then I will ask her about the aggravating factors whereas which makes her sleep better. What will make your sleep worse? What makes her sleeping better. What makes her sleep better at night. What makes her better at interacting with her family members. Does she have sleep disturbance every night? Does it come and go through the week? How severe is your negligence towards your family? Is she completely disconnected from them? Also, I will ask her about suicidal thoughts or sadness all the time. I will ask her if she still has her menstrual cycles and at what age she became menopause. The other question ids she has hot flashes and night sweats which interferes with her sleep. I will assess her appearance, clothing, and hygiene. Are her facial expressions normal, and if she has a sluggish and slow step? I will ask her about her energy levels. The other question will be her patterns of eating if she has any appetite pattern changes (Jarvis, 2016).

Soap Notes

Subjective:

The fifty- two -year old female chief complains and history of her present illnesses (HPI) are missing workdays every week, sleeping during days and cannot sleep at night, and neglecting her family. She denies any past medical history.

I would like to interview the patient about her past history of illnesses, prolonged antibiotic therapies, the name of the antibiotic, and how long she was taking it. Any surgeries in the past, the surgeon name, hospital name, type of surgery, and preventative care, marital status, childhood diseases, accidents, injuries, hospitalizations, operations, her obstetric history, the number of pregnancies, live birth, premature birth, miscarriages, abortions, food allergies, seasonal allergies, mediation allergies, patient's cultural background family health history. Also, I will ask her about and when was her last physical and exam in a medical office and if she had any lab work done. If she had lost or gained weight recently. Also, I want to inquire about her immunization (Jarvis, 2016). I will ask her if she is taking alcohol, illicit drugs, tobacco, or coffee?

Objectives

We obtain vital signs, general observations, orientation level, grooming, dressing, nutritional status based on weight. Assessment of the eyes includes pupil size, reaction to light, conjunctiva, sclera assessment, exudates, and bleeding. Then we move to head, ear, nose, and throat. We assess them for any visible or mass presence, scarring, oral mucosa, pharyngeal exudates, lesions, ear canal patency, and clearance. Then we evaluate the neck for tenderness, jugular distention, bruits, and lymphadenopathy. Respiratory: assessing for lung sounds clarity, wheezing, labor breathing, equal chest expansion. Cardiovascular assessments include heart rate, rhythm, gallop, murmur, strong pulses, capillary refill, and edema. Gastrointestinal assessment consists of checking for soft abdomen, present bowel sounds, hernia, organomegaly. Genitourinary evaluation includes costovertebral angle soreness. Assessments of lymphatics include neck, groin, and axilla lymph nodes for any changes. Evaluations of musculoskeletal are assessing the station, gain, misalignment, reduced range of motion, swelling, soreness, atrophy, and tone of muscles. Integumentary assessments are evaluating for turgor, abnormal bruising, erosions, turgor, warm and dry skin. Neurological examinations include intact sensation and abnormal reflexes. Psychiatric examinations are assessing for alertness, orientation X 3, proper mood, emotions, memory status, and judgment ( Jarvis, 2016).

Pertinent positive: Disturbed sleep pattern, lack of interest in family and work which might be related to depression, menopause, or both.

Pertinent negative: the patient is not on any medication and denies any health issues or allergies for health issues

Assessment:

Based on all system reviews, mental status, and questioner -2 (PHQ-2), the patient has depression.

The differential diagnosis patient may have a sleep disorder or menopause symptoms.

Plan:

Order CBC, CMP, TSH, FSH.

Based on the result of the lab works and depression screening, my diagnosis is depression and insomnia; as a result of a menopausal state.

Treatments

There are additional treatments to complement pharmacotherapy and psychotherapy for mild depression cases. Treatment and management of depression can be promoted by regular physical activities, preventing the depression from becoming worse (Harvard Health Publishing, 2021b). Regular physical activity can reduce anxiety. Forty-five minutes of moderate aerobic exercise three times each weak significantly affects depression improvement (Harvard Health Publishing, 2021b). House projects and gardening are considered physical activities without spending time in gyms (Harvard Health Publishing, 2021b). Another element in improving depression is the proper diet. Reducing refined sugar, processed and fast foods can be beneficial (Harvard Health Publishing, 2021b). Replacing fruit and nuts with unhealthy sweet snacks can improve depression (Harvard Health Publishing, 2021b). Expressing appreciation for any positive life experiences can enhance medial prefrontal cortex activities related to depression (Harvard Health Publishing, 2021b). Social interactions decrease the risk of more severe depression. Joining a favorite club or group activity can be improving depression disorder (Harvard Health Publishing, 2021b).

Dietary supplements seem t be helpful for insomnia. Valerian root, Chamomile, and Melatonin taking one to three mg two to three hours before bed are beneficial ( Harvard Health Publishing, 2021a).

Patient education

Many over-the-counter herbal supplements have some minimal adverse effects such as dizziness, headache, and nausea. They also may enhance the effects of alcohol and other medications. Patients must consult with the health care provider before starting any sleep supplement or over-the-counter sleep medications such as Tylenol or Advil pm ( Harvard Health Publishing, 2021a).

In the end, I will ask the patient how she feels about the health conditions and interventions? Also, I make sure all the patient s questions are answered or if she wants to discuss more issues 9 Jarvis, 2016).

References

Jarvis, C. (2016). Examination and Health assessment. (7th ed.). Elsevier.

Harvard Health Publishing. (2021a). Are drug store sleep-aids safe?

https://www.health.harvard.edu/staying-healthy/are-drugstore-sleep-aids-safe

Harvard Health Publications. (2021b). The no-drug approach to mild depression.

https://www.health.harvard.edu/mind-and-mood/the-no-drug-approach-to-mild-depression

Rush, A., J. (2020). Unipolar major depression in adults: Choosing initial treatment. UpToDate.

https://www.uptodate (Links to an external site.) .com/contents/unipolar-major-depression-in-adults-choosing-initial-treatment?

search=depression%20treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

YesterdayMay 22 at 7:04pm

Excellent! With depression, what other background questions are important to ask?

Thank you,

Dr. Mills