Treating a Patient with a Common Condition Essay
Treating a Patient with a Common Condition Essay
A 75 years old female presents to the primary care office complaining of insomnia. She has a past medical history of hypertension, diabetes, and major depressive disorder. Her current medication is Metformin 500mg BID, Januvia 100mg daily, Losartan 100mg daily, HCTZ 25mg daily, and Sertraline 100mg daily. Her husband of 41years passed on 10 months ago and this worsened her depression and insomnia. She visits her primary care physician twice a year. On examination, she is awake, alert, and oriented. She denies suicidal ideation. Her vitals are blood pressure at 132/86 mmHg, Current weight at 88 kg, and Current height at 64 inches, BMI at 33.3kg /m2, and Temperature at 98.6 degrees F. Treating a Patient with a Common Condition Essay
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Post a response to each of the following:
List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
- How long does it take to fall asleep at night? How often do you wake up in the middle of the night? How long do you take to fall back asleep? These questions help in evaluating the sleeping patterns and the causes of insomnia. A patient with psychological stress has increased cortisol production in the body which causes overstimulation of the brain, hence insomnia.
- How refreshed do you feel when you wake up? This helps the care provider assess the quality of sleep of a patient.
- Do you snore loudly or feel likes gasping when you wake up? This helps to determine if the patient has sleep apnea. Sleep apnea is the commonest cause of insomnia. Causes of sleep apnea are obesity, COPD, and heart failure.
Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
The people in the patient’s life who can give reliable information are her immediate caregiver, her children, and her friends. The questions I would ask them are;
- How does she behave at home?
- How is her mood throughout the day?
- Can she complete her tasks of daily living like bathing and feeding?
Insomnia is a common symptom of depressive mood disorder and psychosis. These questions would help identify the change in behavior of a patient, the mood, and cognitive functions. For example, a patient with psychotic disorder presents with restlessness, bizarre behavior, anger, and increased appetite.
Explain what, if any, physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
I would examine the chest for heart sounds and abnormalities to rule out any heart disease. I would do a thyroid function test to rule out hyperthyroidism. I would do an arterial blood gas test to determine hypoxemia, which is a frequent cause of insomnia due to nocturnal hypoxemia. I would use the Epworth sleepiness scale to assess sleep disturbance and the quality of sleep. The sleep diary would help him assess the sleep-wake cycle in an individual.
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
The differential diagnoses are chronic insomnia, depressive mood disorder, and obstructive sleep apnea. Treating a Patient with a Common Condition Essay
Primary diagnosis: Chronic insomnia is a common sleep disorder characterized by difficulties in sleeping, difficulties in falling asleep, and maintaining sleep throughout the night despite having an opportunity to sleep during day time (Patel, et al, 2018). Patients with chronic insomnia usually have difficulties in coping with stressful situations. The patient reports that insomnia worsened after the death of her husband. The patient has diabetes mellitus, and hypertension, and is obese. These three causes a metabolic syndrome that causes insomnia due to sleep apnea.
Depressive mood disorder is a mental illness associated with a change in mood, behavior, and cognitive functions. The presenting symptoms are insomnia, loss of appetite, suicidal ideation, loss of concentration, and hopelessness (Park, L. T., & Zarate Jr, C. A. 2019). This is not the actual diagnosis because the patient denies suicidal ideation. Moreover, there is no report of behavioral changes.
Obstructive sleep apnea is a cessation of airflow in the presence of respiratory effort. It is a common respiratory collapse during sleep (Veasey, S. C., & Rosen, I. M. 2019). It presents with snoring, nocturia, and insomnia. It is common in patients with obesity, post-menopausal state, and cardiovascular diseases.
List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
- Zolpidem 10mg PO at bedtime
- Suvorexant 10mg PO 30 minutes before bedtime
Suvorexant is an orexin receptor antagonist FDA-approved for chronic insomnia. It reduces hyperarousal and improves sleep consolidation. It has a plasma half-life of 12 hours and achieves its therapeutic goals within three days. It is the best for an elderly patient because it is well tolerated and has minimal side effects (Edinger, et al, 2019). Zolpidem is a short-acting GABA and may cause depression, hallucinations, and delirium.
For the drug therapy, you select and identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?
Suvorexant causes fatigue, somnolence, and headache. It is contraindicated in co-administration with other antidepressants and opioids.
Include any “checkpoints” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.
Follow up with the patient after four weeks to monitor its effectiveness and side effects. I would make therapeutic changes if the patient complained of tachycardia, psychomotor hyperactivity, and anxiety.
The patient is a 55years old female who came for a regular gynecological review at the clinic. She had a cardiac stent at the age of 50 years and mild hypertension, currently on lisinopril, Zocor, and Plavix. She has a past surgical history of tonsillectomy and bunion removal. She is up to date with her colonoscopies and has a history of normal pap smear tests and mammograms with diagnostic investigations. Her menarche was at the age of 14 years and menopause at 52years. She has never been married nor had a child. She has been with her current partner for two years and they will get married in two months. The patient needs guidance because her partner would want a child. The patient has a medical history of hypertension and cardiac disease that she needs to consider before conception. Moreover, she is on drugs contraindicated in pregnancy. However, despite her medical condition, she is on preconception care folate supplementation. She conceives during the second cycle and returns to the clinic after 12 weeks complaining of high blood pressure, facial puffiness, pitting edema, and epigastric pain.
What Are Your Differential Diagnoses?
- Gestational hypertension
- Preeclampsia
- Eclampsia
Gestational hypertension is the elevated blood pressure of more than 140/90 mmHg in patients at less than 20 weeks gestation. It is common in pre-existing hypertension, mother age above 40 years, twin pregnancies, and kidney diseases. The presenting symptoms are high blood pressure, edema, pain in the right upper quadrant, and absence of protein in the urine (Lo, et al, 2020). It is the primary diagnosis because the patient is only twelve weeks pregnant, is 55years old, and has had pre-existing hypertension.
Preeclampsia is an endothelial malfunction disorder that presents with proteinuria ad hypertension in patients above 20 weeks gestation age. The symptoms are high blood pressure of more than 140/90 mmHg, persistent epigastric pain, visual disturbances, progressive renal insufficiency, thrombocytopenia, and pulmonary edema (Rana, et al, 2019). The risk factors are nulliparity, chronic hypertension, age of above 40years, and obesity. However, this is not the patient’s diagnosis despite similar symptoms because she has no proteinuria and is less than 20 weeks gestation. Eclampsia is the presence of convulsions in a patient with preeclampsia.
Why Did You Make This Diagnostic Decision?
Gestational hypertension is the patient’s diagnosis because she has high blood pressure, epigastric pain, lower limb edema, and facial puffiness. Additionally, her gestation age is 12 weeks, she is over 40years, and has never had children.
What Is Your Treatment Plan?
Diagnostic tests: according to Duhig, et al, (2018), renal function tests, liver function tests, urinalysis, and platelet levels help rule out preeclampsia and eclampsia.
Pharmacological treatment
- Nifedipine 20mg PO once daily for hypertension
- Magnesium sulfate for prophylaxis of preeclampsia and eclampsia
Non-pharmacological
Bed rest and fetal monitoring to check the health status of the fetus.
Ethical dilemma in this case study
The ethical dilemma in this situation is the respect for autonomy versus beneficence. Beneficence is having the best interests of patients when selecting a treatment method (Bester, J. C. 2020). In this case, the patient will have a difficult pregnancy due to her advanced age and the presence of chronic diseases like heart failure. Therefore, IVF or child adoption is the best option for the patient to have a child. This is contradicting the patient’s decision regarding the physical conception, pregnancy, and delivery. Autonomy is respect for a patient’s decisions. Treating a Patient with a Common Condition Essay
Psychological issues in this case study
The patient is at risk of having depression and anxiety because she has pre-existing chronic diseases that would threaten her pregnancy. Moreover, hormonal fluctuations in pregnancy cause high and low mood changes.
Physical issues in the case study
The patient has chronic diseases like hypertension and heart disease that would physically affect her during the pregnancy. Chronic hypertension increases the risk for stroke and placenta abruption that would threaten the survival of her pregnancy.
Financial issues in the case study
The patient requires financial resources to help her in consulting a specialist, regular follow-up, and treatment.
Discussion: Treatment for a Patient With a Common Condition
Insomnia is one of the most common medical conditions you will encounter as a PMHNP. Insomnia is a common symptom of many mental illnesses, including anxiety, depression, schizophrenia, and ADHD (Abbott, 2016). Various studies have demonstrated the bidirectional relationship between insomnia and mental illness. In fact, about 50% of adults with insomnia have a mental health problem, while up to 90% of adults with depression experience sleep problems (Abbott, 2016). Due to the interconnected psychopathology, it is important that you, as the PMHNP, understand the importance of the effects some psychopharmacologic treatments may have on a patient’s mental health illness and their sleep patterns. Therefore, it is important that you understand and reflect on the evidence-based research in developing treatment plans to recommend proper sleep practices to your patients as well as recommend appropriate psychopharmacologic treatments for optimal health and well-being.
For this Discussion, review the case Learning Resources and the case study excerpt presented. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs.
Case: An elderly widow who just lost her spouse.
Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications:
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- Metformin 500mg BID
- Januvia 100mg daily
- Losartan 100mg daily
- HCTZ 25mg daily
- Sertraline 100mg daily
Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP: 132/86
Post a response to each of the following:
- List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
- Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
- Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
- List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
- List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
- For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?
- Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen. Treating a Patient with a Common Condition Essay
