Appropriate Physical Examination For Cardio-Respiratory Disease Discussion

The first question would be: do you often wake up feeling out of breath or gasping? This would provide a quick assessment of the functional, cognitive, and cardio-cerebrovascular condition of the patient (Jacobson, 2014). The second question would be: do you use substances, like caffeine, tobacco, and/or alcohol? These stimulants disrupt sleep in the evenings (Jacobson, 2014). And, lastly, do you have a current (besides your husband’s demise) or new stresses, perhaps in your personal life or other areas of your life? Increased stress levels worsen sleep disorders (Garg, 2018)Appropriate Physical Examination For Cardio-Respiratory Disease Discussion. In order to further assess the patient’s situation, I will speak to her caregiver or the older adult in the family. I will ask him/her questions that would somehow determine his/her capability to provide continuous care, such as: do you have children or other dependents at home; do you have a partner, if yes, is s/he supportive?

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Appropriate physical exams that will be carried out will look for cardio-respiratory disease, thyroid disease, lymphadenopathy, and pallor. This is to rule out any physical cause(s) of the patient’s insomnia and depression (Garg, 2018). Blood tests and sleep evaluation (a comprehensive sleep history) are the diagnostic tests that will be carried out. The findings will be used to determine if psychotherapy, alongside pharmacologic medications, would be beneficial (Jacobson, 2014).

Some key differential diagnoses are endocrine (hyperthyroidism, diabetes), pulmonary (asthma), cardiovascular (arrhythmia, congestive heart failure), sleep apnea, and depression (Mai & Buysse, 2008). The most likely is depression as numerous of insomnia’s daytime symptoms (e.g. mood changes, poor concentration) overlap with depression’s symptoms (Victor, Garg, & Gupta, 2019). Two pharmacologic agents that would be most appropriate for the patient are Citalopram (Celexa)— 20 mg/d— and Sertraline (Zoloft)— 200 mg/d. These two are the safest drugs for older adults suffering from MDD symptoms and chronic diseases (e.g. diabetes, hypertension). However, I would choose Citalopram over Sertraline since studies show that it works faster than Sertraline in improving depressive symptoms (Jacobson, 2014)Appropriate Physical Examination For Cardio-Respiratory Disease Discussion.

One contraindication with Citalopram is that it could exacerbate suicidal tendencies and behavior that are not included in the original presenting symptoms (Jacobson, 2014). Hence, the patient’s family must regularly keep in touch with the PMHNP in case there would any sudden behavioral changes. The patient must be closely monitored for suicidal tendencies, clinical worsening, and changes in behavior; this must be carried out throughout the first 1-2 months of dosage adjustments and therapy (Garg, 2018)Appropriate Physical Examination For Cardio-Respiratory Disease Discussion.

References

Garg, H. (2018). Role of optimum diagnosis and treatment of insomnia in patients with hypertension and diabetes: a review. Journal of Family Medicine and Primary Care, 7(5), 876-883.

Jacobson, S. (2014). Clinical manual of geriatric psychopharmacology. American Psychiatric Publication.

Mai, E. & Buysse, D. (2008). Insomnia: prevalence, impact, pathogenesis, differential diagnosis, and evaluation. Sleep Medicine Clinics, 3(2), 167-174.

Victor, R., Garg, S., & Gupta, R. (2019). Insomnia and depression: how much is the overlap? Indian Journal of Psychiatry, 61(6), 623-629. Appropriate Physical Examination For Cardio-Respiratory Disease Discussion