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:
• 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
• 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. Widowed Female with Hypertension Diabetes Mellitus and Major Depressive Disorder Essay
• For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?
Case Study of a 75 Year-Old Widowed Female with Hypertension, Diabetes Mellitus, and Major Depressive Disorder (MDD)
The patient is a 75 year-old female diagnosed with major depressive disorder (MDD) but already having two ore-existing conditions in the form of hypertension and type II diabetes mellitus. Her husband died ten months before and she now presents with insomnia. She has no suicidal thoughts and is oriented in place, time, person, and event. She is currently taking metformin 500 mg orally twice daily, sitagliptin (Januvia) 100 mg orally once daily, losartan 100 mg orally once daily, hydrochlorothiazide 25 mg orally once daily, and sertraline (Zoloft) 100 mg orally once every day. This paper answers questions on the patient’s condition as well as the pharmacotherapy.
Three Questions to Ask
To understand more about the patient through subjective information, best practice requires that the clinician asks targeted questions. These are done respectfully with cultural competence during history taking (Ball et al., 2019). In that context, the three questions that I might ask the patient if they were in my office and their respective rationales are as follows:
- Do you have a dependable social support system of persons in your life who you can talk to and share your problems?
The rationale for this question is that it will enable me to understand the social factors at play in the client’s home environment. Loneliness and the lack of a robust social support system are important factors that are known to exacerbate the symptoms of depression (Sadock et al., 2015). Getting information about close relatives or friends the client can rely on will therefore help explain some of the patient’s symptoms.
- Do you have any living children?
It is important to know whether the client has any living children. This is important in that being elderly; some of the interventions that may be suggested may require that the patient be assisted by a close relative. This may include but not limited to taking the client for walks as a means of isotonic aerobic exercise. This helps relieve stress and boredom as well as being beneficial for sugar control and obesity. The client is obese with a BMI of 32.3 kg/m2.
- What activities do you normally engage in during the day?
It is also important to know the kind of activities that the client is involved in during the day. Normally, persons with insomnia at night normally have a habit of sleeping during the day. Being elderly and occupationally inactive, this could be a likely contributory cause for the client’s insomnia. Widowed Female with Hypertension Diabetes Mellitus and Major Depressive Disorder Essay
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People in the Patient’s Life to Speak To and Appropriate Diagnostics/ Physical Exams
Continuing from the above rationales for the questions that the patient may be asked as above, it is important to know if there are significant people in the patient’s life. These are the people who might shed light on the patient’s actual situation. They include children, siblings, and grandchildren. Some of the questions that they may be asked include:
- What is your current relationship to the patient?
- Are you normally present to help her when she needs assistance of any nature?
- Does she confide in you whenever she feels lonely and depressed?
The reason why these questions are important to ask is that the answers to them will give insight into the kind of support that the patient may have. This includes economic support, social support, and psychological support.
Indeed, there are tests and examinations that would be appropriate for this patient in directing her management. They are (i) the patient health questionnaire-9 (PHQ-9) tool (ii) the Beck Depression Inventory (BDI-II), and (ii) a comprehensive mental status examination or MSE. The PHQ-9 is useful in assessing or measuring the severity of depression, while the BDI-II helps in evaluating depression symptomatology (Willacy, 2019). Lastly, the MSE enables the evaluation of the client’s state of mind and how they view their condition. It will give information about factors such as the patient’s affect, insight, and judgment.
Differential Diagnosis and Pharmacotherapy
According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM-5, two possible differential diagnoses for this client would be:
- Mood disorder due to another medical condition, and
- Adjustment disorder with depressed mood (APA, 2013).
Of these two, the one that I think is the most likely is mood disorder due to another medical condition. This is because based on the results of physical examination and laboratory tests, this client may be found to be suffering from other conditions such as stroke (she is hypertensive), multiple sclerosis, or hypothyroidism (APA, 2013). These are conditions that would produce a similar or close symptom profile.
Two pharmacologic agents would be appropriate for this elderly lady. They are both atypical antidepressants referred to as selective serotonin reuptake inhibitors or SSRIs. They are also both FDA-approved to treat MDD. They are:
- Escitalopram (Lexapro) 20 mg orally once daily
- Sertraline 100 mg orally once daily (Stahl, 2017).
Of these two, I might choose sertraline over escitalopram for this client. This is because apart from having a similar side effect profile to escitalopram, its SEs are known to wane with time as its therapeutic effects get stronger. It is also known to cause some weight loss instead of just increasing weight. This would be beneficial for this obese elderly female. For sertraline as the preferred choice, the dose may need to be reduced if the client is of Chinese descent as it has been shown that they respond to lower doses. Higher doses for them may result in expression of side effects (Stahl, 2017). This exists because apparently the Chinese do not produce high amounts of the metabolic enzymes that break down sertraline.
American Psychological Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Author.
Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9th ed. Elsevier.
Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11th ed. Wolters Kluwer.
Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. Cambridge University Press.
Willacy, H. (November 13, 2019). Screening for depression in primary care. https://patient.info/doctor/screening-for-depression-in-primary-care
Widowed Female with Hypertension Diabetes Mellitus and Major Depressive Disorder Essay