69-year-old Caucasian female presents with a report of depression, insomnia and some memory problems that are not too troubling.
Depression began after husband fell out of an airplane 11 years ago causing his death- reports having had a good supportive relationship with him and just could not believe he had died (with tears); sleep problems since youth worsened after husband’s death- sleeps 4-5 hours nightly without Xanax- wakes after about 1-2 hours of sleep without Xanax; referred by primary care provider who has been prescribing Prozac and Xanax; no romantic relationship since husband’s death though she may consider entering a relationship with the right man.
Depression helped with Prozac and sleep helped with Xanax taken for several years (over 5 years)
Agrees to taper Xanax and begin other sleep medication e.g. trazodone not previously prescribed- denies overuse of Xanax saying she only takes as needed for addiction concern she heard of from friends
Denies any psychiatric hospitalization
MSE: well appearing; well groomed; normal weight for height; pleasant and cooperative; overall WNL with mood generally appearing not depressed; fair insight and judgment; no history of SI, HI, AH, VH
Denies street drug use or alcohol use
Medical hx: Diabetes Mellitus & Hypertension treated with medications
Medications prescribed at visit:
Xanax 1mg po hs prn (was prescribed 1mg bid; has been taking half of one mg bid as needed)
Prozac 40mg one po am
Family & Social hx: lives in owned condo alone; husband died suddenly after falling out of an airplane after 35 years of marriage; two adult children one (son) who has ‘emotional’ issues does not talk about them, and other child (daughter) seeing a psychiatrist since father’s death; practicing Christian; high school education; last worked 3 years ago in sales; has friends with whom she has fun; attends the gym 3 days of the week; 6-year-old grandson hit by a truck in her presence however she does not clearly remember what happened- fractured ribs suffered by grandson; parents of grandson not allowing her to see grandchildren causing tears and sadness (that clear) at visit and a few times weekly; does not attend psychotherapy and this intervention has not been previously suggested to her- agrees to psychotherapy and wants to know what kind of therapy she will receive e.g. CBT she heard of from friends
address each of the following areas-
• Management of health status
• Maintenance of Nurse Practitioner-client relationship
• Teaching
• Professional role i.e. advocacy, ethics, policy, collaboration and consultation, leadership, referrals, research
• Negotiating health care delivery e.g. cost, access, efficacy
• Monitoring quality of care
• Providing culturally sensitive care
• Health promotion and prevention, health protection & treatment
