For this Discussion, review the case Learning Resources and the case study excerpt presented. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs.   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 BP: 132/86  By Day 3 of Week 7 Post a response to each of the following: • 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.  • 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? • Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.  Respond to the these discussions. All questions need to be addressed. Discussion 1 En Three questions to ask the patient and a rationale for asking these questions. How may I be of assistance today? This question creates a rapport between you and the patients, and it makes her know that the doctor is ready to listen and help her. What are you doing to cope with grief after losing your husband? This question will help the care ...

1. For this Discussion, review the case Learning Resources and the
case study excerpt presented. Reflect on the case study excerpt
and consider the therapy approaches you might take to assess,
diagnose, and treat the patient’s health needs.
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

2. Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP: 132/86
By Day 3 of Week 7
Post
a response to each of the following:
• 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.
• For the drug therapy you select, identify any contraindications
to use or alterations in dosing that may need to be considered

3. 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?
• Include any “check points” (i.e., follow-up data at Week 4, 8,
12, etc.), and indicate any therapeutic changes that you might
make based on possible outcomes that may happen given your
treatment options chosen.
Respond to the these discussions. All questions need to be
addressed.
Discussion 1 En
Three questions to ask the patient and a rationale for asking
these questions.
How may I be of assistance today? This question creates a
rapport between you and the patients, and it makes her know
that the doctor is ready to listen and help her.
What are you doing to cope with grief after losing your
husband? This question will help the care provider assess the
approaches the patient is using to cope with grief and be able to
identify the ones working and not working for the patient.
Are you living with someone at home, and are you following
your regimen correctly? By asking this question, the care
provider will understand the type of support system available at
home and know which support to prescribe for the patient and if
the support at home is helping the patient follow her regimen
correctly.
People in the patient’s life to speak to or get feedback from to
further assess the patient

4. People in the patient’s life to speak to include her children, her
aide, and close friend per her authorization. The feedback I will
get from these people will help me know the severity of the
patient's problem. Some of the questions I will ask them are;
1. Has the patient been experiencing worse symptoms of
depression since her husband’s dead? This question will help
me understand people close to her can know when she is
depressed.
2. Does the patient complain about her treatment regimen? This
question will allow me to know the side effects of the treatment
if any.
3. Has the sleeping patterns changes recently? This question
will help me understand the severity of insomnia.
Physical and diagnostic tests
The physical exams appropriate for this patient include heart
rhythm, eye assessment, and oxyhemoglobin saturation. The
diagnostic tests for this patient include polysomnography and
actigraphy tests. These tests will be used to measure the
patient’s sleep patterns. The actigraphy measures sleep
efficiency, sleep latency, and total sleep time, and
polysomnography will diagnose sleep disorders (Niel et al.,
2020)
Differential diagnoses for the patient
The patient's differential diagnoses include generalized anxiety
disorder, major depressive disorder, and restless leg syndrome .
Major depressive disorder (MDD) is likely to explain why the
patient is experiencing insomnia. MDD’s clinical presentation
include insomnia, difficulty concentrating, appetite loss, and

5. hopelessness. The patient’s husband’s loss contributed to
depression, which affected her sleeping pattern. According to
Bennabi et al. (2019), patients with MDD are at risk of
experiencing sleeping disorders. Since the patient is responding
to grief, her chances of developing MDD are high.
Pharmacologic agents and their dosing
Selegiline Transdermal patch. Apply 6mg daily dose, which is
applied every day. If symptoms do not improve, the dose can be
increased by 3mg daily for two weeks until it reaches a
maximum of 12gm daily. The drug inhibits Monoamine
Oxidase-B isoenzyme (Bied et al., 2015).
Eszopiclone. The required dose is 3mg, which is administered
orally before the patient goes to bed. It is the first-line drug for
insomnia, and it interacts with gamma-aminobutyric acid
(GABA) receptors at the allosterically binding sites at the
benzodiazepine receptors. The drug works by slowing brain
activities to allow sleep. The drug induces sedation and
hypnosis hence causing sleep (Dixon et al., 2015). Since the
patient is complaining of insomnia, eszopiclone will be
appropriate in improving this symptom.
Drug therapy contraindications
Contraindications of using selegiline transdermal include
increased risks of serotonin syndrome. The drug contraindicates
in the patients taking selective serotonin reuptake inhibitors,
mirtazapine, and other vasoconstrictors and analgesics.
Check points
After administering these drugs, the patient will be assessed
after a four-week interval to determine if the symptoms have
improved. If the symptoms have not improved after four weeks,

6. selegiline transdermal will be increased by 3mg for four weeks
until 12gm, which is the maximum dose per day. If the
symptoms improve within the first four weeks, the regimen will
be maintained until the patient completes the dose. After
completing the dose, the patient will sleep well and the
symptoms of depression will be well managed.
References
Bennabi, D., Charpeaud, T., Yrondi, A., Genty, J. B.,
Destouches, S., Lancrenon, S., ... & Haffen, E. (2019). Clinical
guidelines for the management of treatment-resistant
depression: French recommendations from experts, the French
Association for Biological Psychiatry and
Neuropsychopharmacology and the fondation FondaMental.
BMC psychiatry
,
19
(1), 1-12.
https://doi.org/10.1186/s12888-019-2237-x
Bied, A. M., Kim, J., & Schwartz, T. L. (2015). A critical
appraisal of the selegiline transdermal system for major
depressive disorder.
Expert review of clinical pharmacology
,
8
(6), 673-681.
https://doi.org/10.1586/17512433.2016.1093416
Dixon, C. L., Harrison, N. L., Lynch, J. W., & Keramidas, A.
(2015). Zolpidem and eszopiclone prime α1β2γ2 GABAA
receptors for longer duration of activity.
British journal of pharmacology
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172

7. (14), 3522-3536.
https://doi.org/10.1111/bph.13142
Niel, K., LaRosa, K. N., Klages, K. L., Merchant, T. E., Wise,
M. S., Witcraft, S. M., Hancock, D., Caples, M., Mandrell, B.
N., & Crabtree, V. M. (2020). Actigraphy versus
polysomnography to measure sleep in youth treated for
craniopharyngioma.
Behavioral sleep medicine
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(5), 589-597.
https://doi.org/10.1080/15402002.2019.1635133