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Case 1: Volume 2, Case #16: The woman who liked late-night TV 
Post a response to the following:

Provide the case number in the subject line of the Discussion.
List three questions you might ask the patient if he or 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 physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
List three differential diagnoses 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 sleep/wake 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.
If your assigned case includes “check points” (i.e., follow-up data  at week 4, 8, 12, etc.), indicate any therapeutic changes that you  might make based on the data provided. 
Explain “lessons learned” from this case study, including how you  might apply this case to your own practice when providing care to  patients with similar clinical presentations. 

* Four References Required
* No PlagiarismPATIENT FILE

The Case: The woman who liked late-night TV

The Question: What to do when comorbid depression and sleep disorders
are resistant to treatment

The Dilemma: Continuous positive airway pressure (CPAP) may not be a
reasonable option for treating apnea; polypharmacy is needed but
complicated by adverse effects

Pretest self-assessment question (answer at the end of the case)

Which of the following hypnotic agents is less likely to be addictive, impair
psychomotor function, or cause respiratory suppression?

A. Ramelteon (Rozerem)
B. Zolpidem (Ambien)
C. Doxepin (Silenor)
D. Temazepam (Restoril)
E. A and C
F. B and D
G. None of the above

Patient evaluation on intake
• 70-year-old female with a chief complaint of “being sad”
• Feels she had been doing well until her hearing began to diminish in

both ears
– Candidate for cochlear implants in the future, but this is a long way off
– Despite the promise of improved hearing, she often has crying spells

for no clear reason

Psychiatric history

• The patient has been without psychiatric disorder throughout her life
• Has felt increasingly sad over the last year and these feelings were not

triggered by an acute stressor
• Lives alone with the help of a home aide

– Her spouse died many years ago due to CAD
– Despite her aide and her son who visits often, she is having a

harder time coping with both instrumental and basic activities of
daily living

• She admits to full MDD symptoms
– She is sad, has lost interest in things she used to enjoy, and is

fatigued with poor focus and concentration
– Denies feelings of guilt, worthlessness, or any suicidal thoughts
– Appears mildly psychomotor slowed
– Additionally states that sleep is “awful”
◦ Does not fall asleep easily as her legs “ache and jump”


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◦ Takes frequent naps during the day as a result
◦ She admits to snoring frequently

• There is no evidence of cognitive decline or memory problems
• She has a supportive son who accompanies her to all appointments and

helps provide her care

Social and personal history

• Graduated high school, was married, and raised her children
• Denied any academic issues, learning disability, or ADHD symptoms

growing up
• Having and maintaining friendships has been easy and successful over

the years
• At times, she is lonely at home
• Her mobility has declined somewhat, which limits her going out
• Participates in activities at a local elders’ center
• No history of drug or alcohol problems

Medical history

• Hypothyroidism
• Anemia
• Environmental allergies
• Obesity

Family history

• Reports AUD throughout her extended family
• MDD reportedly suffered by her mother

Medication history

• Never taken psychotropic medications

Psychotherapy history

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