1a) Identify two (2) additional questions that were not asked in the case study and should have been?
The first question that was not asked is how Mrs. Gomez managed her grieving after the loss of her husband. “Have you ever talked to someone about the loss of your husband?”
The second question that should have been asked is about the patient’s work and any recent changes in work schedules. “Have you experienced any changes in your work routine?”
1b) Explain your rationale for asking these two additional questions.
During the time of bereavement and throughout the grieving process, a person requires emotional support to overcome the loss of the loved one. It would be important to understand if Mrs. Gomez found any support to aid in recovery and acceptance of the loss. This question can help to determine if the patient’s insomnia is related to complicated grief (American Cancer Society, 2019). Mrs. Gomez’s insomnia could also be a result of recent changes to her work shifts or schedules. It is important to understand if she works somewhere or has been involved in house chores outside the normal working hours.
1c) Describe what the two (2) additional questions might reveal about the patient\’s health.
These two questions can help the primary care provider understand the emotional well-being of Mrs. Gomez. Emotional health is an important part of overall health because it affects how people control their thoughts, feelings, and behaviors (American Cancer Society, 2019). The questions may help reveal if the patient has negative emotions that affect her sleep and if she’s aware of them. Additionally, the healthcare provider can assess if a prolonged feeling of sadness and hopelessness could be contributing to depression that manifests with signs like insomnia.
2a) Explain the reason the provider examined each system.
Mrs. Gomez is a 65-year-old female patient presenting to the clinic with a chief complaint of difficulty sleeping. Apart from this complaint, Mrs. Gomez is an elderly patient who is at risk of conditions like diabetes, dementia, hypertension, and many others that normally affect the elderly. It was important to conduct a head to toes examination to ascertain the patient’s physical and psychological well-being. Examination of all body systems could help identify other health problems that could be contributing to insomnia or health conditions that the patient could not be aware of. The systems examined include respiratory, cardiac, gastrointestinal, endocrine, neurologic, and urologic systems. The review of these systems helped to refine the steps of the diagnostic process and avoidance of unnecessary tests.
2b) Describe how the exam findings would be abnormal based on the information in this case.
The patient reports increased weight gain as a result of inactivity, eating junk foods, and probably stress or depression. Constitutional findings showed that she had gained 10 lbs in the last six months.
2c) Describe the normal findings for each system.
The physical examination findings for the patient include: Pulse is 60 beats/minute and regular, Respiratory rate is 16 breaths/minute, Blood pressure is 128/78 mm Hg, Weight is 84 kg (186 lbs (up 10 lbs since last year)), Height is 163 cm (64 in). Assessment of HEENT revealed no masses, thyromegaly, or adenopathy. The cardiovascular system examination revealed a regular heart rate and rhythm with no murmurs, gallops, or edema on the extremities. The respiratory system was clear on auscultation and abdominal examination revealed a soft, no-tender stomach with no masses or organomegaly. Neurologically, cranial nerves 3 to 12 were intact, the patient had a normal gait, no tremors and there was normal strength and light touch sensation. The review of systems was non-remarkable.
2d) Identify the various diagnostic instruments you would need to use to examine this patient.
Assessment of the patient’s vitals will require the use of instruments like a stethoscope, blood pressure machine, weighing scale, and thermometer. Additional instruments for assessment may include a penlight to examine the eyes and the ears for any abnormalities.
Discuss the pathophysiology of the:
3a) Diagnosis and,
The established diagnosis for Mrs. Gomez is major depressive disorder (MDD). This condition has a significant potential for mortality and morbidity because it leads to suicide, substance abuse, and disruption of personal relationships (Nemeroff, 2020). The pathophysiology of depression is not well-established but is thought to involve an interaction of neurotransmitters in the brain. The disruption of CNS serotonin (5-HT) activity is a major factor evidenced by the effectiveness of SSRIs in managing depression (Nemeroff, 2020). Other neurotransmitters that are implicated to lead to depression include norepinephrine, dopamine, and glutamate. Another important aspect of major depressive disorder pathophysiology is a shift of seasons from fall and winter to spring and summer. Seasonal affective disorder, a form of MDD, is thought to be caused by alterations in CNS levels of 5-HT.
3b) Each Differential Diagnosis
Based on the patient’s age and clinical presentation, the first differential diagnosis is dementia. Dementia is a term that refers to a combination of symptoms like the inability to remember, think, or make decisions that interfere with everyday activities (Alzheimer’s Association, 2022). The condition is common among elderly patients with advancing age being the greatest risk factor. The development of dementia is associated with molecular mechanisms like hypoxia and oxidative stress, neuroinflammation, neurodegeneration, and blood-brain barrier permeability (Alzheimer’s Association, 2022). Alzheimer’s disease characterized by widespread atrophy of the cerebral cortex and neurodegeneration is another common mechanism of dementia development.
The second differential diagnosis for Mrs. Gomez is hypothyroidism. Hypothyroidism can be primary, due to permanent loss or atrophy of functional thyroid tissue, or secondary due to insufficient stimulation of the thyroid gland (Duntas & Yen, 2019). A localized disease of the thyroid gland is the most common cause of hypothyroidism. Normally, the thyroid gland releases T3 and T4 hormones at a certain balance to maintain homeostasis. Small amounts of T3 are required to maintain activity, but during the disease process, hypertrophy and hyperplasia of the thyroid gland cause oversecretion of T3 that suppresses T4 activity (Duntas & Yen, 2019). The result is altered metabolism that is evidenced by weight gain, low mood, impaired cognition, and cardiac symptoms among many others.
4a) What labs should be ordered in the case?
Laboratory investigation, in this case, will include a complete blood count (CBC) to rule out organic causes like anemia and thyroid-stimulating hormone (TSH) to detect if hypothyroidism is the cause for the observed symptoms.
4b) Discuss what lab results would be abnormal.
In this case, we do not anticipate laboratory investigations to be abnormal because Mrs. Gomez’s insomnia is caused by depression. However, a low T4:T3 ratio can indicate a diagnosis of hypothyroidism. Anemia can also be observed based on the CBC results.
4c) Discuss what the abnormal lab values indicate.
Abnormal TSH levels will indicate hypothyroidism. A high T3 and low T4 will probably indicate appropriate hypothalamic response to low hormone levels and the thyroid gland’s inability to respond to adequate stimulation (Duntas & Yen, 2019). Low amounts of both hormones from the tests will indicate secondary hypothyroidism.
4d) Discuss what diagnostic procedures you might want to order based on the medical diagnosis.
The diagnostic procedure I will want to order for Mrs. Gomez is screening for depression using the geriatric depression scale (GDS) short form. This tool is easy to use and takes about 5 to 7 minutes to complete. I will also want to order a Mini-Cog exam to screen for dementia.
5a) Risk factors for insomnia
Insomnia is often the result of a behavior or a symptom of an underlying mental or physical problem. The use of over-the-counter medications like decongestants, phenytoin, and steroids can increase the risk for insomnia (Krystal et al., 2019). The elderly aged 65 years and above are more likely to have insomnia than young people. Other factors include poor sleep environment, female gender, and drug abuse.
5b) Lack of sleep and consequences
Lack of sleep is linked with short and long-term consequences to an individual’s health. Lack of sleep causes lack of alertness, excessive daytime sleepiness, impaired memory, the risk for accidents, and decreased quality of life (Centers for Disease Control and Prevention, 2020). There is a close link between lack of sleep and the development of chronic illnesses like heart disease, type 2 diabetes, and depression.
Alzheimer’s Association. (2022). Alzheimer’s & dementia. https://www.alz.org/alzheimers-dementia/what-is-dementia
American Cancer Society. (2019). Seeking help and support for grief and loss: The importance of support during the grief process. https://www.cancer.org/treatment/end-of-life-care/grief-and-loss/depression-and-complicated-grief.html
Centers for disease Control and Prevention. (2020). Sleep and sleep disorders. https://www.cdc.gov/sleep/index.html
Duntas, L. H., & Yen, P. M. (2019). Diagnosis and treatment of hypothyroidism in the elderly. Endocrine, 66(1), 63-69. https://doi.org/10.1007/s12020-019-02067-9
Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: An update. World Psychiatry : Official Journal of the World Psychiatric Association (WPA), 18(3), 337–352. https://doi.org/10.1002/wps.20674
Nemeroff, C. B. (2020). The state of our understanding of the pathophysiology and optimal treatment of depression: Glass half full or half empty?. American Journal of Psychiatry, 177(8), 671-685. https://doi.org/10.1176/appi.ajp.2020.20060845
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