NSG 6001 Week 4 Mental Health Discussion
Chief Complaint: “I’m just so tired lately. I just can’t seem to sleep.”
HPI: cannot sleep for more than a couple of hours before waking with a lack of energy and
inability to
...
NSG 6001 Week 4 Mental Health Discussion
Chief Complaint: “I’m just so tired lately. I just can’t seem to sleep.”
HPI: cannot sleep for more than a couple of hours before waking with a lack of energy and
inability to focus for the past six months. Lost husband in last year. No longer participates in
activities such as church and reading. Denies pain, trouble breathing, snoring, physical
restlessness disturbing sleep. Rarely consumes caffeine or alcohol. Treatments tried include:
Tylenol PM and herbal zapote blanco without positive results. (Hay, 2018)
PMH: hypercholesterolemia, Type 2 diabetes, hypertension; cholecystectomy, hysterectomy;
Glyburide 10mg daily, Metformin 1000mg bid (diabetes); Lisinopril 10mg daily, propranolol
40mg bid (hypertension); atorvastatin 80mg daily (cholesterol); aspirin 81mg daily (CHD
prevention); calcium citrate with vitamin D (osteoporosis prevention)
Family History: None
Social History: Hispanic widow, living with daughter; Nonsmoker; small amounts of alcohol on
holidays.
Objective Data:
Vital Signs: BP – 128/78; P 60; R 16; fWt.186lbs; Ht. 64in; BMI 24.8
Physical Assessment Findings:
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 organomegal or masses.
Neurologic: Cranial nerves 3-12 intact. Normal strength and light touch sensation in
extremities. No tremors. Normal gait. (Hay, 2018, physical exam)Mental Health: Denies intent to self-harm.
Laboratory and Diagnostic Test Results: CBC, TSH, and complete metabolic panel;
Geriatric Depression Scale – Short Form – 9 (>5 consistent with depression diagnosis); The
Mini-Cog exam – normal (dementia screening); Patient Health Questionnaire – 9 – 8/9.
(Hay, 2018)
Assessment:
Major Depressive Disorder: social withdrawal, loss of interest, insomnia, inability to
concentrate; GDS-SF score of 9. (Hay, 2018; Buttaro, Trybulski, Polgar-Bailey, &
Sandberg-Cook, 2017)
Hypothyroidism: depression, fatigue, weight gain. TSH no results. (Hay, 2018; Buttaro et al.,
2017)
Dementia: depression, passiveness, attention or concentration changes, personality changes;
Mini- Cog exam normal. (Hay, 2018; Buttaro et al., 2017)
Plan of Care:
Medications: sertraline 25mg daily due to pt symptoms, current conditions and medications.
Smaller initial dose due to patient age (reduced by 50%); may take up to 4-6 weeks for full
effects. Change propranolol to amlodipine 5mg daily due to propranolol’s depressive effects.
(Hay, 2018; Buttaro et al., 2017)
Education: be sure to continue to take the medication even if you do not notice effects
immediately they take several weeks to begin working; exercise is also beneficial. Family
support is important for the pt. Side effects of sertraline include: headache, nausea, diarrhea,
and sleepiness. (Hay, 2018; Buttaro et al., 2017)Follow-up in a couple of weeks to check in and see how you are doing; also to take a look at
labs to ensure no other conditions are present. Come in if symptoms are worsening or
experience side effects from the medication. (Hay, 2018)
References
Buttaro, T. M., Trybulski, J., Polgar-Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A
collaborative practice (5th ed.). St. Louis, MO: Elsevier
Hay, W. (2018). Family medicine 03: 65-year-old woman with insomnia. Retrieved from
https://southu-nur.meduapp.com/document_set_document_relations/30223
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