Discuss the Mrs. Gomez’s history that would be pertinent to her difficulty sleeping. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.
Describe the physical exam and diagnostic tools to be used for Mrs. Gomez. Are there any additional you would have liked to be included that were not?
Please list 3 differential diagnoses for Mrs. Gomez and explain why you chose them. What was your final diagnosis and how did you make the determination?
What plan of care will Mrs. Gomez be given at this visit, include drug therapy and treatments; what is the patient education and follow-up?
REASON FOR VISIT:
On further questioning, Mrs. Gomez denies any discomfort such as pain or breathing problems disturbing her sleep. She denies any snoring, apneic spells (a period of time during which breathing stops or is markedly reduced), or physical restlessness during sleep. Her daughter agrees that she has not seen these problems. She rarely consumes alcohol or caffeine.
When you ask if anything like noise or an uncomfortable sleeping environment might be bothering her, she replies that this is not a problem – but her daughter interjects: “Yes, in fact Mom’s waking up the rest of us, walking around and turning on the TV. My husband and I both work. So we all need our rest. Mom came to live with us last year after Dad passed away. We’re her only family around here and we thought we should help her.”
She seems to be in slow motion most of the time. She doesn’t even go to church anymore. She used to go three to four times a week. She used to read all the time, and she doesn’t do that anymore either.”
Mrs. Gomez explains, “I haven’t been reading as much as I used to because I can’t seem to focus and I end up reading the same page over and over.” She goes on to say, “And I don’t seem to have any energy to do anything. I’m not even able to help out around the house. I feel bad about that; I should be helping out more. I seem to spend a lot of time just watching TV and eating junk food.”
PAST MEDICAL HISTORY
Type 2 diabetes
Hysterectomy (due to fibroids)
Glyburide (10 mg daily)
Metformin (1,000 mg bid)
For blood pressure:
Methyldopa (250 mg bid)
Lisinopril (10 mg daily)
Atorvastatin (80 mg daily)
For CHD prophylaxis:
Aspirin 81 mg daily
For osteoporosis prevention:
Calcium citrate with vitamin D (600mg/400 IU bid)
Diphenhydramine is her only over-the-counter medication, and she is taking no traditional or herbal medications beyond the zapote tea.
She does not smoke, and drinks only small amounts of alcohol on holidays.
Given what you have heard from Mrs. Gomez and her daughter, especially
her inability to focus,
her lack of energy,
the sense that she is in slow motion,
she has stopped doing activities she previously enjoyed,
You are concerned that her insomnia may be due to depression. Depression may stem from environmental stressors such as her husband’s death and her loss of independence along with a primary neurochemical imbalance. Her depression also could be caused by another medical condition.
REVIEW OF SYSTEMS:
Keeping in mind the disorders associated with depression, you elicit a review of systems from Mrs. Gomez to help discover what these indicate regarding her underlying illness.
Constitutional: Mrs. Gomez has gained about 10 lbs in the last six months. She denies fevers or dizziness. This makes you less concerned about cancer or other systemic illness.
Respiratory: No shortness of breath, making cardio-respiratory disease less likely.
Cardiac: No chest pains, palpitations or edema, decreasing the likelihood of cardiovascular disease.
Gastrointestinal: No nausea, changes in bowel habits, hematochezia or melena. This makes you less concerned about gastrointestinal cancer or occult blood loss leading to anemia.
Endocrinologic: No polydipsia or polyuria, decreasing the likelihood of poorly controlled diabetes.
Neurologic: No acute neurologic changes or tremors. Her daughter confirms that patient has been alert, oriented and has had no episodes of confusion. So you are now less concerned about cerebral infarction, intracranial tumors, multiple sclerosis, and Parkinson disease.
Urologic: Normally urinates one to two times at night.
Heart rate: 60 beats/minute and regular
Respiratory rate: 16 breaths/minute
Blood pressure: 128/78 mm Hg
Weight: 186 pounds (up 10 pounds since last year)
Height: 64 in
Head, eyes, ears, nose and throat (HEENT): No thyromegaly, adenopathy, or masses.
Cardiac: Regular rate and rhythm, no murmur or gallops. No edema.
Respiratory: Clear to auscultation.
Abdominal: Soft, nontender, without organomegaly or masses.
Neurologic: Cranial nerves 3-12 intact. Normal strength and light touch sensation in extremities. No tremors. Normal gait.
You locate Dr. Lee and present the case to her, expressing your concern that Mrs. Gomez is depressed. She suggests discussing the evidence you found that Mrs. Gomez may have depression.
You tell Dr. Lee, “Mrs. Gomez has depressed mood and seven of the nine criteria.”
Major Depression Diagnostic Criteria
For a diagnosis of major depression, the patient must have at least five of the following nine criteria for a minimum of two weeks.
A least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure.
(The eight remaining criteria can be remembered using the mnemonic SIG E CAPS):
Sleep: Insomnia or hypersomnia nearly every day.
Interest (loss of): Anhedonia (loss of interest or enjoyment) in usual activities.
Guilt: Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
Energy (decreased): Fatigue or loss of energy nearly every day.
Concentration (decreased, or crying): Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
Appetite (increased or decreased): or significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month).
Psychomotor retardation: Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
Suicidal ideation: Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
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