Treatment of Patients with Common Conditions Discussion

The patient provided in the case has a past history of major depressive disorder, diabetes mellitus and hypertension and reports symptoms of insomnia. Depression can make it very difficult to manage blood sugar and pressure which can result into associated complications which may be life threatening (Jovinally, 2022). Insomnia is also a common symptom of depression characterized by chronic dissatisfaction in the quantity and quality of sleep which is associated with a difficulty in falling asleep and maintaining sleep (Levenson, 2015).

In case the patient was in my office, I would ask questions like: “How do you feel about the loss of your husband?”. This will help me determine whether she is undergoing the normal grieving process and will help her open up about her feelings. I would also ask her whether she experiences nightmares in her sleep to determine whether she is experiencing some post-traumatic stress disorder. Finally, I would ask her if she has any social support system. This is important as she will be able to express herself to someone in case her depression worsens and with the social support, she can be able to contact someone in case of an emergency. Treatment of Patients with Common Conditions Discussion

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Some of the people in the patient’s life that I would need to speak to include her children, if any or someone she stays with and keeps close contact with. Some specific questions I may ask them regarding the patient’s condition include their observation whether they have observed any abnormal behaviour in the patient since her husband’s demise and whether she tries to keep in contact with them or isolates herself. This is important as it will help determine the severity of the depressive symptoms and any abnormal coping mechanisms which may be dangerous to the patient’s health.

Some physical examinations that can be done include performing a mental status examination to determine the patient’s mental process and establish a diagnosis. Polysomnography can be used to diagnose several sleep disorders including sleep apnea, restless leg syndrome and parasomnia. To diagnose depression, laboratory tests such as a CT scan or MRI of the brain to help rule out presence of serious illnesses such as a brain tumor, Electrocardiogram to diagnose heart problems and electroencephalogram (EEG) to record the brain’s electrical activity (Bruce, 2020).

Some differential diagnoses for this patient include bipolar mood disorder and major depressive disorder. The most likely diagnosis for this patient is adjustment disorder with a depressed mood. This is because the patient is most likely still grieving after the loss of her husband and being that her depressive symptoms worsened after the death of her husband, she is possibly experiencing an adjustment disorder. Treatment of Patients with Common Conditions Discussion

Managing the patient’s insomnia will go hand in hand with managing the depression (Abbott, 2016). Temazepam (Restoril), 15mg can be used at bedtime. Another medication that can be used is Triazolam (Halcion), 0.25mg at bedtime. In the management of the insomnia, I would choose Temazepam over Triazolam because Temazepam will help the patient sleep and also keep the patient asleep while triazolam will only help the patient fall asleep.

Temazepam is contraindicated in patients with suicidal thoughts because it can trigger the suicidal ideations and cause precipitate suicide attempts. Other conditions that are contraindicated in this case include alcohol intoxication and drug abuse because it can increase the nervous system side effects such as dizziness, difficulty concentrating and drowsiness. Special considerations should be made for dosage adjustments in patients with renal impairment. The dosage should be reduced because of reduced drug clearance which can result into toxicity. Treatment of Patients with Common Conditions Discussion

Follow up should be made after 2 weeks to determine the effectiveness of the drug and the necessity to stop the medication, adjust the dosage or change the medication entirely. The medication dosage can be adjusted in case the desired effects are not being achieved. With development of severe complications such as increase in suicidal ideation, the medication should be stopped and another favourable one prescribed.

References

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://doi.org/10.1378/chest.14-1617

Jovinally, J. (2022). Is there a link between diabetes and depression? Know the facts. Retrieved on 14^th July 2022 from https://www.healthline.com/health/type-2-diabetes/depression

Bruce, D.F. (2020). Tests used to diagnose depression. Retrieved on 14^th July 2022 from https://www.webmd.com/depression/guide/depression-tests

Abbott, J.O. (2016). What’s the link between insomnia and mental illness? Retrieved on 14^th July 2022 from https://www.sciencealert.com/what-exactly-is-the-link-between-insomnia-and-mental-illness Treatment of Patients with Common Conditions Discussion

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.

Reference: Abbott, J. (2016). What’s the link between insomnia and mental illness? Health. https://www.sciencealert.com/what-exactly-is-the-link-between-insomnia-and-mental-illness#:~:text=Sleep%20problems%20such%20as%20insomnia%20are%20a%20common,bipolar%20disorder%2C%20and%20attention%20deficit%20hyperactivity%20disorder%20%28ADHD%29 Treatment of Patients with Common Conditions Discussion

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: Treatment of Patients with Common Conditions Discussion

Metformin 500mg BID
Januvia 100mg daily
Losartan 100mg daily
HCTZ 25mg daily
Sertraline 100mg daily
Current weight: 88 kg

Current height: 64 inches

Temp: 98.6 degrees F

BP: 132/86

By Day 3 of Week 7
Post a response to each of the following:

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.

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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. Treatment of Patients with Common Conditions Discussion

RESOURCES:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/

Freudenreich, O., Goff, D. C., & Henderson, D. C. (2016). Antipsychotic drugs. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 72–85). Elsevier. Treatment of Patients with Common Conditions Discussion