NURS 5002 Case Study #5

Refer to Case Study Grading Guidelines and Grading Rubric for a complete description of requirements and
grading criteria. To make the case study as real as possible, while you are working through the case study
do not look ahead at the information provided.

You are working in an Internal Medicine office and Paul, a 75 year-old has an appointment for tiredness and
insomnia. You review his chart:

PMH SH MEDS
HTN -Retired (maintenance worker at ASA 81 mg daily
Chronic headaches, poor peripheral local plant, military service 10 Olmesartan 20mg daily
vision both related to trauma years) Vytorin 10/40 daily
sustained in the military -Lives with second wife of 3 yrs.
GERD (first wife of 31 yrs. died 5 years PRN:
Hypercholesterolemia ago from a CVA) Ergotamine tartrate
Cholecystectomy 30 yrs. ago - Social alcohol (3-5 beers a few Excedrin Migraine
times a week) Tylenol
- 2-3 caffeine sodas/week Aleve
- ppd smoker Ibuprofen
- denies drug use Tums
-Hobby- woodworking Pepcid OTC
FH
Mother HTN, GERD, high Allergies:
cholesterol, died from heart attack Meperidine rash, vomiting
age 84
Father smoker, depression, died
from colon cancer age 67

As you prepare for this visit what are your primary concerns? First degree relative (dad) history of colon
cancer and depression. Current caffeine, alcohol, and tobacco use. First degree relative (mother) with
history of hypertension, hypercholesterolemia, and heart attack. Is his blood pressure and cholesterol well
controlled? Use of Tums and Pepcid OTC. How often does he use these medications? Is he troubled with
symptoms of GERD, if so all of the time or certain times of the day (morning/ night)? Soda, alcohol, and
tobacco can all cause excess stomach acid, which can contribute to GERD. What time of the day does he
use these items? He has a history of GERD, which can be painful and aggravating, this could possibly be
keeping him up at night. Chronic headaches and use of PRN Excedrin migraine. Common side effects of
Excedrin migraine are upset stomach, heartburn, depressed mood, feeling anxious or restless, and sleep
problems such as insomnia (Drugs.com, 2016e).

What are your primary questions to ask Paul? Has he had a colonoscopy, if so how long ago? Any blood tinged, dark stools, or
abdominal pain/ discomfort? Constipation or laxative use? First degree relative (dad) with colon cancer at age 67, genetics is a risk
factor for colon cancer and fatigue is a clinical manifestation (Doig & Huether, 2014, p. 1469-1471). Has he ever experienced
symptoms of anxiety or depression in the past? Has he experienced similar symptoms that his dad experienced with depression? How
is he coping with the loss of his first wife (just because he is remarried does not necessarily mean he is coping well with losing his
wife of 31 years)? First degree relative (dad) with history of depression, family and twin studies show a strong relationship with mood
disorders (such as depression), insomnia is a clinical manifestation (Takahashi, 2014, p. 647). Does he consume heavy meals, alcohol,
or caffeine late in the day or before bedtime? Is anything troubling him or on his mind or has he been under any stress recently? Has
he been sick or in pain recently? According to Chanin (2014), some factors related to secondary insomnia include stress, illness,
physical or emotional pain, or substance use, such as caffeine or alcohol. How often does he have headaches, how long do symptoms
last, and are symptoms relieved with medications? In my experience, I have found it hard to sleep or get good rest when I have
headaches. How often does he use Excedrin migraine?

Upon Assessment of the patient you find the following information:

Paul states he feels very tired all the time and he is unable to sleep through the night. He awakens several
times and typically gets up at 5-6am but is tired by 9-10 am. Paul states he has tried Unisom and
Melatonin but they didnt seem to help. This has been going on for a long time, maybe 4-5 years, but it has
been getting worse over the last 1-2 years. Now I just have to go back to bed or take a nap on the couch.
I am so tired that I cant even work in my workshop anymore. My other wife used to love for me to make
things for her out there. Paul states he has promised to make his granddaughter a doll bed but I am just
no really up to it but I dont want to let anyone down. My wife is complaining constantly and I just dont
know what else to do. Paul states he has been down in dumps on and off since his first wife died. He went
to counseling for a while and tried a brief round of Prozac but states he did not like it.
He also states he hasnt been eating very much and his stomach has been hurting more with more
indigestion so he has had to take more Tums and some extra Pepcid just to get it to feel better. I just dont
feel like I have enough energy to carry on anymore or if it really matters.

Physical Exam
General- NAD, clean-shaven, appropriately dressed, appears stated age
EENT PERRL, neck supple, no adenopathy, significant dental work for caries upper and lower, mucosa pink and
moist without ulceration, no oral odors , TMs grey with minor accumulation of cerumen R>L, no bulging or
retractions noted
Neuro- alert and oriented x 3, speech clear, gait steady
Heart RRR no mrg, pedal pulses 2+, radial pulses 2+, no ankle/pedal edema, no carotid bruits bilat
Lungs CTA bilat ant and post
Abdomen- soft, non-tender, BS x 4 quads, no organomegaly
Genitalia deferred

VS
HR: 90 BP 140/88 RR 18 T 98.8F Ht: 511 Wt: 180lbs

Are there any other questions you would like to ask Paul based on the initial information you have obtained? Does he feel that he is coping well
after his first wifes passing? Is his second wife supportive? Has he spoken to his second wife about the way he is feeling and how long that he
has been having these symptoms? Does anything seem to make his symptoms better or worse? Has his second wife ever attended counselling
sessions with him in the past? (In past experience sometimes barriers in communication can cause a lot of misunderstanding and undue depression
and anxiety.) Any thoughts of suicide? What did he not like about the Prozac/ what symptoms did he experience? Is the bedroom dark and have
appropriate temperature (not too hot/cold)? Does he do any type of work in the bedroom, or does he just use the bedroom to sleep? Does he take
naps through the day? Does he try to go to sleep around the same time each night? What types of foods does he eat? Do some foods bother his
stomach more than others? Does the TUMS and extra Pepcid relieve his symptoms? What are typical blood pressures (140/88 is elevated)?

DIFFERENTIATION OF DISEASE (may add other columns if needed)

Make sure to add references for information

DISEASE #1 DISEASE #2 DISEASE #3 DISEASE #4

Insomnia Depression Anxiety PUD
Pathophysiology Sleep disorder Variant in the serotonin Generalized anxiety Duodenal Ulcer: Risk
characterized by transporter (5-HT-T) disorder (GAD): factors such as family
difficulty falling or that exists as either a Abnormalities in the history, Helicobacter
staying asleep. short or long allele. norepinephrine and pylori (H. pylori),
Primary insomnia is The serotonin serotonin systems habitual use of non-
when a person has transporter serves in (Takahashi, 2015, p. steroidal anti-
insomnia that is not the reuptake of 655). inflammatory drugs
associated with any serotonin at the Panic disorder: Some (NSAIDs), alcohol,
health problem or any synapse and may studies suggest the smoking, acute
other reason. moderate the cholecystokinin pancreatitis, chronic
Secondary insomnia serotonergic response receptor gene on obstructive pulmonary
is when a person has to stress (Takahashi, chromosome 11p may disease, obesity,
insomnia because of 2015, p. 648). be linked to panic cirrhosis, and being
some other reason or disorder. It is believed older than 65 years,
problem. Factors that heightened pH cause acid and pepsin
related to secondary sensitivity in the concentrations in the
insomnia include: amygdala generates duodenum to penetrate
stress, illness, fearful perceptions the mucosal barrier
physical or emotional activating the cerebral and lead to ulceration.
pain, environmental cortex and neuronal (Doig & Huether,
factors, medications, circuits in the 2014, p. 1435)
or substance use such temporal lobe and Gastric Ulcer:
as caffeine or alcohol brainstem. May also Frequently caused by
(Chanin, 2014). involve the GABA- H. pylori, chronic
benzodiazepine pangastritis, duodenal
receptor system reflux of bile (seen
(Takahashi, 2015, p. after cholecystectomy,
654). pyloroplasty, or
gastrojejunostomy, or
 pyloric sphincter
failing to respond to
stimuli that normally
increases resting tone
(such as entry of acid,
protein, and fat into
the duodenum)
allowing reflux of bile
and pancreatic
enzymes to damage
the gastric mucosa.
The damaged mucosa
allows hydrogen ions
to diffuse into the
mucosa, this disrupts
permeability and
cellular structure,
histamine causes
increased acid and
pepsinogen
production, blood
flow, and capillary
permeability. The
disrupted mucosa
swells and loses
plasma proteins, small
vessel destruction
causes bleeding (Doig
& Huether, 2014, pp.
1437-1438).
Signs/Symptoms Sleepiness during the Unremitting feelings of GAD: Restlessness, Duodenal Ulcer:
day, general tiredness, sadness and despair, muscle tension, Typical age of onset
irritability, and insomnia, loss of irritability, easily 20-50 years old. Pain
 problems with appetite and body fatigued, difficulty when stomach is
concentration and weight, reduced concentrating, and empty and is relieved
memory (Chanin, interest in pleasurable difficulty sleeping immediately with
2014). activities and (Takahashi, 2015, p. ingestion of food or
interpersonal 655) antacids. Some have
relationships, sleep Panic disorder: no symptoms, and first
disturbances, reduced Lightheadedness, manifestations may be
motor activity and tachycardia, difficulty hemorrhage or
fatigue, feelings of breathing, chest perforation, especially
worthlessness and discomfort, with history of NSAID
guilt, perceive generalized sweating, or anticoagulant use.
pessimistic or negative generalized weakness, Pattern of remission
outcomes, diminished trembling, abdominal and exacerbations
ability to function and distress, chills or hot (Doig & Huether,
concentrate (Takahashi, flashes, worry, and 2014, pp. 1435-1437).
2015, pp. 650-651). agoraphobia Gastric Ulcer: Typical
(Takahashi, 2015, p. age of onset 50-70
654). years old. Pain occurs
immediately after
eating. Cause
anorexia, vomiting and
weight loss. Tend to
be chronic (Doig &
Huether, 2014, pp.
1437-1438).
Treatments: Treatment of any Antidepressant drugs GAD: 5- Duodenal Ulcer and
underlying conditions such as MAOIs, TCAs, HT/norepinephrine Gastric Ulcer:
that may be causing SSRIs, and SNRIs and/ reuptake inhibitors Relieving the causes
insomnia. Behavioral or psychotherapy. (such as venlafaxine) and effects of
approaches including: Electroconvulsive or SSRIs (paroxetine increased acid and
trying to go to sleep therapy (ECT) can be or escitalopram), prevention of
at the same time each used when individuals buspirone, along with complications.
night and getting up fail to respond to behavior therapy for Antacids (neutralize
at the same time each antidepressants or in relaxation (Takahashi, gastric contents,
morning, avoid naps severe depression, 2015, p. 655). elevate pH, inactivate
during the day, make pregnancy, suicidal, or Panic disorder: pepsin, relieve pain,
your bedroom psychotic episodes Cognitive behavior and are
comfortable (dark, (Takahashi, 2015, p. therapy (CBT) and/or cytoprotective), H2
quiet, not too hot or 651). antidepressant receptor blockers
too cold) and avoid medications (SSRIs (inhibit acid
using your bedroom and SNRIs), and secretion), proton
for anything other benzodiazepines. pump inhibitors (PPI)
than sleep, avoid Relaxation techniques (inhibit acid
caffeine, nicotine, (breathing exercises to production), treatment
alcohol, and large control and eradication of H.
meals late in the day, hyperventilation) pylori (with bismuth,
a light snack late in Takahashi, 2015, pp. combination of
the evening may help 654-655). antibiotics, and
you sleep, get regular vitamin C), ulcer-
exercise but do not coating agents to
exercise right before promote healing
bedtime, try (sucralfate and
relaxation techniques colloidal bismuth),
before bed (reading, anticholinergic drugs
listen to music, taking (inhibit gastric
a bath), make a to do secretion) (Doig &
list or journal entry to Huether, 2014, p.
try and get thoughts 1437).
off of your mind
before bed.
If all other techniques
and interventions fail,
a rapid, short-acting
sleeping pill may be
prescribed for a
limited time.
 Avoid over the
counter sleep aids as
they may have
undesired side effects
and loose
effectiveness over
time (Chanin, 2014).

Complications: Persons suffering Suicidal risk increases GAD: Tends to be Increased risk of
with insomnia reports and having depression chronic and frequent cancer with gastric
a decrease in quality at midlife or older ages complication is ulcers (Doig &
of life. Physical and contribute to suicide in substance abuse, Huether, 2014, p.
mental problems can 10%-15% of depressed which may result from 1437).
result in lack of sleep. persons (Takahashi, self-medication with
Some complications 2015, p. 651). alcohol or drugs to
include: lower relieve anxiety
performance at work symptoms (Takahashi,
or school, slowed 2015, p. 655).
reaction time, Panic disorders:
depression or anxiety, Agoraphobia is a
weight gain, complication which in
irritability, increased severe cases can cause
risk of obtaining or a person to become
complications housebound
associated with long (Takahashi, 2015, p.
term medical 654).
conditions, and
substance abuse
(Mayo Clinic, 2014).

What is your disease choice

for the given scenario? Check
box for your choice or place X
in box.

Why did you make this disease choice? Give a good rationale for your decision. The patient states that his insomnia and tiredness has
been going on for a long time, approximately 4-5 years. His first wife of 31 years passed away 5 years ago and Paul states that he has
been down in the dumps on and off since his first wife died. He got remarried three years ago. Paul states that his symptoms have
been getting worse over the past 1-2 years. He states that his wife is complaining constantly. It seems to bother Paul because he
promised to make his granddaughter a doll bed and states he does not feel up to it right now but he also does not want to let anyone
down. He has not been eating much and stomach has been hurting with indigestion. Paul states that he does not feel like he has
enough energy to carry on anymore or if it really matters. According to Takahashi (2014), some of the signs and symptoms of
depression include unremitting feelings of sadness and despair, insomnia, loss of appetite, reduced interest in pleasurable activities and
interpersonal relationships, sleep disturbances, reduced motor activity and fatigue, feelings of worthlessness and guilt.

COMPARISON OF MEDICATION (may add other columns if needed)

Make sure to add references for information if all your information for a medication is from one source then you can list it once and make a notation.

MEDICATION #1 MEDICATION #2 MEDICATION #3 MEDICATION #4

Escitalopram
Class/Type of med Selective Serotonin
Reuptake Inhibitor
(SSRI)
Mechanism of Action The S-enantiomer is
assumed to be linked
to potenation of
seritonergic activity in
the central nervous
system (CNS)
resulting in its
inhibition resulting in
its inhibition of CNS
Desvenlafaxine
Serotonin and
Norepinephrine
Reuptake Inhibitor
(SNRI)
Exact mechanism is
unknown. Thought to
be related to the
potenation of serotonin
and norepinephrine in
the CNS, through the
inhibition of their
reuptake.
Buspirone Alprazolam
Anxiolytic Benzodiazepine
Exact mechanism is Exact mechanism is
unknown. May have unknown. Cause a
affinity for brain D2- dose-related CNS
dopamine receptors. depressant activity
varying from mild
impairment to
hypnosis.
 neuronal reuptake of
serotonin (5-HT)

Indications Major depressive Major depressive Anxiety disorders Anxiety disorder,

disorder, generalized disorder panic disorder
anxiety disorder

Side Effects Common side effects Nausea, vomiting, dry Commonly observed: Drowsiness, fatigue,
include: nausea, mouth, dizziness, dizziness, nausea, impaired coordination,
sleepiness, weakness, insomnia, anxiety, headache, memory impairment,
dizziness, feeling fatigue, chills, nervousness, light-headedness,
anxious, trouble nervousness, vertigo, lightheadedness, and depression, headache,
sleeping, sexual tinnitus, urinary excitement. confusion, insomnia,
problems, sweating, hesitation, jitteriness, May also cause: non- nervousness, syncope,
shaking, anorexia, dry hyperhidrosis, specific chest pain, dizziness, akathisia,
mouth, constipation, constipation, syncope, tiredness/ sleepiness,
infection, yawning somnolence, anorexia, hypo/hypertension, dry mouth,
Other side effects and male function dream disturbances, constipation, diarrhea,
include: increased disorders. depersonalization, nausea/ vomiting,
thirst, abnormal dysphoria, noise increased salivation,
increase in muscle intolerance, euphoria, tachycardia/
movement, nose bleed, fearfulness, loss of palpitations,
difficult urination, interest, hypotension, blurred
heavy menstrual hallucinations, vision, rigidity,
periods, possible involuntary tremor, dermatitis,
slowed growth rate movements, slowed nasal congestion,
reaction time, suicidal weight gain/ loss
ideation, and
seizures.
Complications Suicidal thoughts or Suicidal ideation is May cause physical
Suicidal thoughts or tendencies have been one of side effects. and/ or psychological
tendencies have been reported. Use in caution with dependence.
reported. A gradual reduction in kidney or liver Controlled substance,
A gradual reduction in the dose, instead of impairment. schedule IV.
the dose, instead of abrupt discontinuation Grapefruit juice and Alcohol generally
abrupt discontinuation of the medication is erythromycin have should not be used
of the medication is recommended in order been known to with benzodiazepines.
recommended in order to reduce the chance of increase plasma The elderly may be
to reduce the chance of adverse symptoms. concentration. more sensitive to the
adverse symptoms. Should not be Should not be used drug and may exhibit
Should not be administered in concomitantly with higher plasma
administered in patients being treated MAOIs. concentrations of the
patients being treated with MAOIs, drug due to clearance
with MAOIs, intravenous methylene of the medication.
intravenous methylene blue, other serotonergic The smallest dose
blue, other drugs, including possible should be
serotonergic drugs, triptans, tricyclic used to prevent ataxia
including triptans, antidepressants, and over sedation.
tricyclic fentanyl, lithium,
antidepressants, tramadol, buspirone,
fentanyl, lithium, tryptophan, and St.
tramadol, buspirone, Johns Wort due to the
tryptophan, and St. chance of developing
Johns Wort due to the serotonin syndrome
chance of developing (high fever, muscle
serotonin syndrome spasms, stiff muscles,
(high fever, muscle rapid change in heart
spasms, stiff muscles, rate or blood pressure,
rapid change in heart confusion, and/ or loss
rate or blood pressure, of consciousness).
confusion, and/ or loss Has been known to
of consciousness). increase blood
Has been known to pressure, caution
increase blood should be used in
pressure, caution patients with pre-
should be used in existing hypertension,
patients with pre- cardiovascular or
existing hypertension, cerebrovascular disease
cardiovascular or that may be affected by
cerebrovascular increase in blood
disease that may be pressure.
affected by increase in SSRIs and SNRIs may
blood pressure. increase risk of
SSRIs and SNRIs may bleeding, should be
increase risk of used in caution with
bleeding, should be aspirin, NSAIDs,
used in caution with warfarin and other
aspirin, NSAIDs, anticoagulants.
warfarin and other Should be prescribed
anticoagulants. with caution in patients
Should be prescribed with seizure disorder.
with caution in Hyponatremia may
patients with seizure occur with SSRI and
disorder. SNRI use, and is
Hyponatremia may thought to be caused
occur with SSRI and by syndrome of
SNRI use, and is inappropriate
thought to be caused antidiuretic hormone
by syndrome of secretion (SIADH).
inappropriate Should be used in
antidiuretic hormone caution in the elderly,
secretion (SIADH). hyponatremia has
Should be used in occurred, and in renal
caution in the elderly, and liver impairment.
hyponatremia has There have been
occurred, and in renal teratogenic effects to
and liver impairment. the fetus when taken
There have been while pregnant
teratogenic effects to (pregnancy risk
 the fetus when taken category C.
while pregnant Concomitant use with
(pregnancy risk alcohol is not advised
category C. due to increased risk of
Concomitant use with adverse effects and
alcohol is not advised drowsiness.
due to increased risk of
adverse effects and
drowsiness.

References (Drugs.com, 2016d) (Drugs.com, 2016c) (Drugs.com, 2016b) (Drugs.com, 2016a)

What is your choice for the

given scenario?
(place X in box)

Why did you make this choice? Give good rationale for your decision. I chose Buspirone because the patient currently consumes 3-5
beer few times per week, alcohol should be used in extreme caution or avoided with use of escitalopram, desvenlafaxine, and
alprazolam (Drugs.co, 2016a; Drugs.com, 2016c, Drugs.com, 2016d). Even with counseling of the importance not to use alcohol with
these medications, if he has used alcohol for a long period of time, or if others in the home or persons he is around socially are
consuming alcohol the likelihood of him also drinking alcohol is increased. Insomnia and trouble sleeping are also side effects of
escitalopram and desvenlafaxine, which is the patients chief complaint (Drugs.com, 2016c; Drugs.com, 2016d). Escitalopram and
desvenlafaxine, both should be used in caution in the elderly due to the increased likelihood of developing syndrome of inappropriate
antidiuretic hormone secretion (SIADH) (Drugs.com, 2016c; Drugs.com, 2016d). The elderly also have increased chance of
hyponatremia if kidney or liver function is impaired when taking escitalopram or desvenlafaxine, if prescribing this medication labs
should be monitored in order to keep an eye on this (Drugs.com, 2016c; Drugs.com, 2016d). Paul has a history of discontinuation of
Prozac because he did not like it. Escitalopram and desvenlafaxine should not be discontinued abruptly due to the increased risk of
adverse reactions from the medications (Drugs.com, 2016c; Drugs.com, 2016d). Elderly patients have increased sensitivity to
alprazolam and should be used in caution in these patients, as well as alprazolam is a controlled substance with tendency for addiction
and abuse (Drugs.com, 2016a).

What are other potential choices you could make? Due to the diagnosis of depression escitalopram or desvenlafaxine would be my second choices.
Alprazolam would possibly aid with sleeping, but has a tendency for addiction and abuse. By helping to fix the problem of depression, hopefully
the chief complaint of insomnia and tiredness, as well as many other signs and symptoms he is experiencing will resolve. Any of the medications
would be appropriate for a diagnosis of depression as well as chief complaint of insomnia and tiredness. I feel that with the appropriate
counselling of smoking cessation, signs of SIADH and hyponatremia, importance of not stopping these medications abruptly, and risk of over
sedation with alprazolam any of these medications would be a good choice. Education is key with any new medications, and should be stressed
the importance of communication with the healthcare provider about side effects experienced with medications.

References

Chanin, L. (2014, August 21). An overview of insomnia. In WebMD.com. Retrieved from: http://www.webmd.com/sleep-

disorders/guide/insomnia-symptoms-and-causes

Doig, A. K. & Huether, S. E. (2014). Alterations of digestive function. In K. L. McCance, S. E. Huether, V. L. Brashers & N. S. Rote

(Eds.), Pathophysiology: The biologic basis for disease in adults and children (7th ed.) (pp. 1423-1485). Saint Louis, MO:

Elsevier Mosby.

Drugs.com [Internet]. (2016a). Alprazolam. In drugs.com retrieved from: http://www.drugs.com/pro/alprazolam.html

Drugs.com [Internet]. (2016b). Buspirone. In drugs.com retrieved from: http://www.drugs.com/pro/buspirone.html

Drugs.com [Internet]. (2016c). Desvenlafaxine. In drugs.com retrieved from: http://www.drugs.com/pro/desvenlafaxine-er-

tablets.html

Drugs.com [Internet]. (2016d). Escitalopram. In drugs.com retrieved from: http://www.drugs.com/pro/escitalopram-oral-solution.html

Drugs.com [Internet]. (2016e). Excedrin migraine. In drugs.com retrieved from: http://www.drugs.com/mtm/excedrin-migraine.html

Mayo Clinic [Internet]. (2014, April 04). Diabetes and conditions: Insomnia complications. Retrieved from:

http://www.mayoclinic.org/diseases-conditions/insomnia/basics/complications/CON-20024293

Takahashi, L. K. (2015). Neurobiology of schizophrenia, mood disorders, and anxiety disorders. In K. L. McCance, S. E. Huether, V.

L. Brashers & N. S. Rote (Eds.), Pathophysiology: The biologic basis for disease in adults and children (7th ed.) (pp. 641-659).

Saint Louis, MO: Elsevier Mosby.