Aquifer Study NSG6020
Complete only the Aquifer Study NSG6020 History, Physical Exam, and Assessment sections of the Aquifer virtual case: Family Medicine 03: 65-year-old female with insomnia.
You are required to answer all the DISCUSSION QUESTIONS listed below in each domain.
1a) Identify two (2) additional questions that were not asked in the case study and should have been?
1b) Explain your rationale for asking these two additional questions.
1c) Describe what the two (2) additional questions might reveal about the patient’s health.
DOMAIN: PHYSICAL EXAM
For each system examined in this case;
2a) Explain the reason the provider examined each system.
2b) Describe how the exam findings would be abnormal based on the information in this case. If it is a wellness visit, based on the patient’s age, describe what exam findings could be abnormal.
2c) Describe the normal findings for each system.
2d) Identify the various diagnostic instruments you would need to use to examine this patient.
DOMAIN: ASSESSMENT (Medical Diagnosis)
Discuss the pathophysiology of the:
3a) Diagnosis and,
3b) Each Differential Diagnosis
3c) If it is a Wellness, type ‘Not Applicable
DOMAIN: LABORATORY & DIAGNOSTIC TESTS
Discuss the following:
4a) What labs should be ordered in the case?
4b) Discuss what lab results would be abnormal.
4c) Discuss what the abnormal lab values indicate.
4d) Discuss what diagnostic procedures you might want to order based on the medical diagnosis.
4e) If this is a wellness visit, discuss what the U.S. Preventive Taskforce recommends for patients in this age group.
Aquifer Study NSG6020 Scenario
You are doing an eight-week clerkship in a family medicine practice. You review the EMR (electronic medical record) for the next patient, which identifies the patient as Mrs. Gomez, “a 65-year-old female who is here today reporting that she can’t sleep.”
Dr. Lee, your preceptor, fills you in: “Mrs. Gomez has been a patient here for several years. Difficulty sleeping is a new issue for her. Her past medical history is significant for hypertension and diabetes. Generally, she has been doing well, although I notice that her last hemoglobin A1c has climbed to 8.7%.”
After discussing these potential causes of insomnia with Dr. Lee, you feel prepared to talk with Mrs. Gomez. You knock on the exam room door and enter to find Mrs. Gomez, who is accompanied by her daughter, Silvia. You introduce yourself and ask if you may ask her a few questions, to which she agrees.
“What brings you to the clinic today?”
“I’m just so tired lately. I just can’t seem to sleep.”
“Tell me more about this.”
“Well, for the last six months I can’t sleep for more than a couple of hours before I wake up,” Mrs. Gomez tells you.
On further questioning, Mrs. Gomez reports no discomfort, such as pain or breathing problems disturbing her sleep. She reports no 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 bother 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 here and thought we should help her.”
You tell Mrs. Gomez,
“I’m sorry to hear about your husband.”
“Yes, we were married for 30 years. This has been a difficult time for me.”
“Do you find that you feel sad most of the time?”
“Of course, I am sad when I think about my husband and how much I miss him. But I wouldn’t say I’m sad most of the time.”
Silvia states, “But Mom, you spend most of your time just moping around the house.” Turning to you, she elaborates, “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 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 repeatedly.” She says, “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 much time watching TV and eating junk food.”
“Have you tried anything to help you sleep?”
“Well, I tried Tylenol PM (acetaminophen and diphenhydramine), which didn’t help and gave me a dry mouth. I also tried zapote blanco, a kind of Mexican herbal tea. But it didn’t help me sleep either.”
“I’m unfamiliar with that product, but I’ll mention it to Dr. Lee. I’m glad you brought it up. Your doctors must know about everything you are taking, whether it’s prescription medication or not. I’m sorry, but nothing seems to be helping you sleep. We’ll get to the bottom of this together.”
You turn your attention to taking Mrs. Gomez’s past medical history. You learn:
â€¢ Type 2 diabetes
â€¢ Hysterectomy (due to fibroids)
â€¢ Glyburide (10 mg daily)
â€¢ Metformin (1,000 mg bid)
For blood pressure:
â€¢ Methyldopa (250 mg bid)
â€¢ Lisinopril (10 mg daily)
â€¢ Atorvastatin (80 mg daily)
For CHD prophylaxis:
â€¢ Aspirin (81 mg daily)
For osteoporosis prevention:
â€¢ 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 tiny amounts of alcohol on holidays.
Given what you have heard from Mrs. Gomez and her daughter, especially
â€¢ Her inability to focus
â€¢ Her lack of energy
â€¢ The sense that she is in slow motion
â€¢ 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, her loss of independence, and a primary neurochemical imbalance. Her depression also could be caused by another medical condition.
Considering 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 reports no 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 her mother has been alert, oriented, and has had no episodes of confusion. So you are now less concerned about cerebral infarction, intracranial tumours, multiple sclerosis, and Parkinson’s disease.
Urologic: Normally urinate one to two times at night.
Once you have completed your review of systems, you excuse yourself from the room for a moment while Mrs Gomez changes into a gown.
When you return to the exam room, after washing your hands, you perform a physical exam on Mrs. Gomez.
â€¢ Pulse is 60 beats/minute and regular
â€¢ Respiratory rate is 16 breaths/minute
â€¢ Blood pressure is 128/78 mm Hg
â€¢ Weight is 84 kg (186 lbs (up 10 lbs since last year))
â€¢ Height is 163 cm (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 are afraid your next question may upset Mrs. Gomez, but you know it is important to ask: “Mrs. Gomez, I have one more question: When people are down, sometimes they wish they would fall asleep and never wake up.
“Have you had any thoughts of dying or causing harm to yourself?”
“Well, it has been hard and I would like to see my husband, but I could never hurt myself because of my religion,” she tells you.
“Okay, thank you for your openness with me,” you tell Mrs. Gomez. “I would like to bring in Dr. Lee so she can also perform a physical exam before you get dressed. We’ll be back in just a minute. Do you have any questions for me before I go?”
Mrs. Gomez indicates she doesn’t have any concerns, so you exit the room.
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 a depressed mood and seven of the nine criteria.”
“You seem to have established that Mrs. Gomez meets the criteria for a major clinical depression,” says Dr. Lee
You express to Dr. Lee your concern that by asking about suicide you may have made the situation worse.
Dr. Lee reassures you: “Many people worry that bringing up the subject of suicide will cause the patient to commit suicide. On the contrary, talking about it allows the opportunity to intervene and prevent a completed suicide.”
Entering the room with you, Dr. Lee greets Mrs. Gomez and her daughter, and thanks them for allowing you to interview them.
She tells Mrs. Gomez, “I understand that you’ve been having trouble sleeping – not unusual given your recent stresses. These can also lead to feelings of depression. I’d like to look into this by going over a short questionnaire with you.”
Dr. Lee goes over the questions on the Geriatric Depression Scale – Short Form (GDS-SF) with Mrs. Gomez. Her score equals 9. This confirms depression, as a score of > 5 is consistent with the diagnosis of depression.
Dr. Lee then performs a Mini-Cog exam to screen for dementia, explaining to Mrs. Gomez that in cases like this, checking out the patient’s memory and concentration can help to rule out other disorders and can assist in planning treatment. She scores in the normal range.
I’m glad Mrs. Gomez mentioned trying out a traditional herbal treatment,” Dr. Lee tells you, “This is the sort of thing you don’t want to miss. Do you know anything about zapote?”
You quickly search a drug program on your smartphone and an online database and identify a couple of websites that discuss zapote and its suggested uses, but not much else.
When you re-enter the exam room, Dr. Lee sits down to talk with Mrs. Gomez, “I would like to do a few tests to rule out any medical problem that might be causing your symptoms. But it looks as though you may be suffering from depression, which is completely understandable given the recent changes in your life.
“This may also explain the increase in your blood sugar: Depression takes away your energy and motivation, so it’s hard to summon the effort to stick to a diet or even remember to take your medication regularly.”
After discussing the options for treatment and the various SSRIs, Mrs. Gomez agrees to try sertraline (Zoloft). Dr. Lee writes a prescription for sertraline 25 mg daily, which is well tolerated and available in a generic form. She tells Mrs. Gomez, “Possible side effects include headache, nausea, diarrhea, sleepiness, and (infrequently) insomnia. Because of your age and other medical problems, I’m starting with a moderate dose, but we may increase it later if you don’t have an adequate response.”
Dr. Lee is also worried that Mrs. Gomez’s methyldopa may be aggravating her depression, so she substitutes amlodipine 5 mg daily. This would also be in line with current blood pressure research.
Next, she suggests,
“Mrs. Gomez, another treatment that is very effective for depression is talking with a therapist.”
Mrs. Gomez shakes her head, “Counseling sounds expensive. Besides, I’d rather talk with my priest than some stranger.” Dr. Lee tells her that talking with her priest may be helpful, but a priest’s training is different. Dr. Lee encourages her to consider still one or two visits with a counsellor to see if she gets any benefit from it, and that there are community mental health centres that will see patients on a sliding scale payment basis if cost is a barrier.
You recommend Mrs. Gomez try to get some exercise, possibly walking at the local mall. She agrees to try this. And you give Mrs. Gomez and her daughter a handout about the diagnosis of depression and a list of community resources for people struggling with depression.
Dr. Lee reviews the plan with Mrs. Gomez and her daughter: “We will order the blood tests to make sure no other medical conditions are causing your symptoms. I will order a hemoglobin A1c to see how your diabetes is doing. We may need to adjust your diabetes medicine.”
“Do you have any other questions?” Dr. Lee asks Mrs. Gomez and her daughter. They shake their heads no.
Dr. Lee then concludes the visit: “It will probably take four to six weeks before the medication becomes effective, but it is best if I see you before then – let’s say in two weeks – to monitor your progress and discuss any problems or side effects; we will also review your tests and see if anything else needs to be done. Please feel free to call or come in sooner than that if you have concerns, feel worse, or experience side effects that prevent you from continuing to take your medication.”
On a return visit to Dr. Lee’s office two months later, you see Mrs. Gomez is on the schedule. It is her first visit to the clinic since your previous encounter. Her daughter is in the waiting room.
When you ask how she’s been doing, she says, “Just terrible. I still can’t sleep, and now I find that I’m crying all the time.” She admits that she never started her sertraline and didn’t get the lab tests. She was worried that people would think she’s crazy. She also felt that she should be able to handle her feelings without using drugs.
You ask her what she thinks is wrong with her. She replies she simply thinks she is grieving the loss of her husband. She’s been trying to use prayer to overcome it, but this hasn’t worked so far.
I worry about my daughter,” Mrs. Gomez says tearfully through the interpreter. “She’s just so angry all the time.” At this point, Mrs. Gomez starts to cry. You attempt to comfort her momentarily and then retrieve Dr. Lee for assistance.
Dr. Lee offers Mrs. Gomez a tissue and holds her hand. After a moment, she asks,
“Mrs. Gomez, can you tell me why you are worried about your daughter?”
She replies, “It’s just that Silvia is so short-tempered and cries a lot. I feel bad because I know I’m a terrible burden on the family, causing Silvia a lot of stress.”
Dr. Lee responds,
“I have to ask, has your daughter ever hurt or threatened you?”
Mrs. Gomez reports no.
A quick exam finds no bruises or other signs of abuse.
Dr. Lee explains to Mrs. Gomez that you and she will talk with Silvia and will be back in a moment.
You and Dr. Lee interview Sylvia alone. She admits finding the demands of caring for her mother increasingly draining.
Assuring her that it is common for adult children to find themselves caring for both their parents and their children (a situation sometimes referred to as the “Sandwich Generation”), Dr. Lee directs Silvia to a website (http://www.familyaware.org/) for families dealing with depression. The website includes the following:
â€¢ Lay-oriented educational materials on depression
â€¢ Resources on how to deal with their emotional reactions to the illness
â€¢ Lists of support groups
When you have answered her questions, you excuse yourselves from the room.
Dr. Lee states that she doesn’t feel there is much risk for abuse in this case, although a provider should keep an eye open for it in such taxing situations.
You and Dr. Lee return to speak with Mrs. Gomez about her depression.
“I can appreciate your concern about the diagnosis of depression,” says Dr. Lee. “I hope it will help to know that these feelings you are having are very common: More than 14 million Americans experience depression in any given year. I see lots of people who are depressed in this clinic, and they are not ‘crazy.’ Depression is not a weakness of character that you should try to deal with on your own. It’s a medical condition just like your diabetes. And just like you take medication to help control your diabetes, we have medication to help with depression. This problem can be severe and unlikely to clear up anytime soon without appropriate help.”
“But I am afraid I won’t have the same feelings if I take medication,” Mrs. Gomez interjects, “I don’t want to change who I am.”
Dr. Lee explains, “I am glad you shared your concern. I want to assure you that the medication won’t change who you are; in fact, I believe that this medication will help allow you to be more like you normally are. I also know you are concerned about Silvia and how she’s dealing with her stress. This is the best thing you can do, not only for yourself but also for your family.”
Mrs. Gomez replies, “Well, I suppose it can’t hurt to try the medicine. I don’t seem to be getting better on my own.”
Dr. Lee then replies, “Great. I know this is hard for you to do, but I think you will find it helpful. Once you start taking the medication, you may start feeling better as quickly as within a week. But you probably won’t feel the full effects for about two months. Try not to get discouraged. Depression can be very frustrating. It will take time for your depression to go away.”
Dr. Lee re-prescribes the sertraline and Mrs. Gomez assures her that she will try it this time. Dr. Lee also reorders the lab tests and refers Mrs. Gomez to the local government Department of Aging to see if there are any support services they might provide.
After Mrs. Gomez and her daughter leave, Dr. Lee advises you, “It is common to have difficulty getting an older adult to adhere to an antidepressant regimen.”
You see Mrs. Gomez and her daughter again about two months later when you return to Dr. Lee’s clinic.
“So nice to see you, Mrs. Gomez!”
“How are you feeling?”
“It’s good to see you also. I’m feeling so much better. I sleep all night, have more energy, and have a lighter mood. The medicine Dr. Lee gave me made me a little nauseous initially, but when I talked with her about it, she told me it was normal and would subside. So, I continued the sertraline, and the nausea disappeared after two weeks. I tried to exercise as you suggested, but my arthritis just bothered me too much.”
Today her score on the Geriatric Depression Scale is 4, which is in the normal range.
Silvia adds, “Mom has made new friends at church and has become involved with a group of women there that she spends time with several days a week. It’s nice to see her retaking an interest in things. It takes a huge weight off my shoulders, as well. Thank you for all of your help.”