There are different types of depression disorders whose level of treatment varies with the extent of severity. Some of these disorders include Dysthymic disorder, Melancholic depression, seasonal affective disorder, major depression disorder, subsyndromal depression, psychotic depression among others (Linde et al., 2015). This paper explains the pathophysiology of symptoms for depression, peripheral neuropathy and diabetes, their pharmacological medications and congruence with practice guidelines, the effectiveness of medication as well as self-management education for diabetes.
Pathophysiology of Symptoms: Diabetes, Peripheral Neuropathy and Depression
The pathophysiology symptoms of diabetes include frequent urination, feeling very thirsty, feeling very hungry even when you eat, blurry vision, extreme fatigue, bruises/cuts which are slow in healing, tingling, numbness in feet/hands or pain for type 2 diabetes. There is also the issue of weight loss even when you eat more for the case of diabetes type 1. The clinical results which indicated finger stick blood glucose of 200 in the first and second visits for Jeff is an indication that he is diabetic. This is because the result is outside the normal range of 100-125 ( Zinman et al., 2015) .
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The symptoms of Peripheral Neuropathy comprise of falling and lack of coordination, extreme sensitivity to touch, freezing or burning pain, sharp, jabbing, throbbing, pricking or tingling in hand or feet which can spread to both arms and legs and slow onset of numbness. Since Jeff has a good number of these symptoms, there is likelihood of the presence of Peripheral Neuropathy is caused by diabetes mellitus which appeared positive in two separate clinical tests clear ( Zhao et al., 2015) .
Depression is also characterized by a number of symptoms. They include difficulty in concentration, difficulty in making decisions, feeling of discouragement, remembering things, decreased energy plus fatigue with little interest in doing things, overreacting, lack of good sleep worthlessness, helplessness, feeling of guilt, feeling of hopelessness and pessimism. These symptoms are very much in line with the ones reported by Jeff, implying that he is also suffering from depression. His clinical exam data shored blood pressure of 192/62 is excessively above the normal blood pressure of less than 120/90. This high blood pressure must have been caused by depression in Jeff. At cellular level, the human stress response comprise of sophisticated pathway of signals among neurons plus somatic cells which are stimulated by stress from both environment and neurons within the hypothalamus of the brain (Linde, et al., 2015).
Pharmacological Basis of Medications and Congruence with Practice Guidelines
The use of lisinopril will help in the treatment of high blood pressure which is the result of depression. Metformin is administered for the treatment of diabetes type 2 while duloxetine helps in the treatment of depression peripheral neuropathy by relieving nerve pain in individuals with diabetes. These medications are similar to those given to Jeff during his first clinical visit with continuation of the same during the second visit. The treatment using lisinopril and duloxetine are all similar in the previous and new treatment. However, medication using metformin has been increased to 1000mg PO twice a day in the new treatment from 500mg PO twice a day in the previous treatment. This means that there was no significant change after first medication in the level of diabetes type 2 which still showed clinic finger stick blood sugar of 200 in the second visit as it was in the previous one ( Zinman et al., 2015, Linde et al., 2015, Zhao et al.,2015) .
The medication using lisinopril and duloxetine are maintained at 20mg and 40 mg daily in both the two visits. This is because of some significant changes observed after the first treatment such as decreased blood pressure to 138/80 from the previous 162/92. The new medication targets the blood pressure of at most 120/90. The medication process for Jeff has thus followed the clinical practice guidelines for the treatment of depression, diabetes and peripheral neuropathy.
The mechanism of action by lisiprosil is such that it inhibits angiotensin-converting enzyme in human body. The angiotensin-converting enzyme then catalyzes the angiotensin 1 conversion to the substance called vasoconstrictor, that is, angiotensin 2 which on the other hand stimulates the secretion of aldosterone through the adrenal cortex. The mechanism of action by metformin includes decreasing the production of liver glucose while at the same time increasing the sensitivity of insulin, thus increasing the uptake of peripheral glucose. It thus decreases the blood sugar mainly through the suppression of glucose production by the liver. Deluxetine works by affecting neurotransmitters by inhibiting the uptake of serotonin as well as norepinephrine ( Porth, 2015) .
Effectiveness of Metformin and Duloxetine
The treatment of diabetes type 2 using metformin seemed to be less effective with the first prescription of 500mg PO daily during the first clinical visit by Jeff. This was indicated by no change in blood sugar during the second visit. Perhaps this is why the prescription was increased to 1000 mg PO daily during the second clinical visit . On the other hand, medication using duloxetine seemed to be effective since the blood pressure decreased during the second visit. However, the blood pressure, 138/30 which was lower compare to the previous one was still higher. Therefore the prescription maintained the dosage at 40mg PO daily so that Jeff could continue with the same treatment. However, the ineffectiveness of metformin might have been affected by other factors such as failure or forgetting to take medicine at the frequency prescribed, unimproved diet or even lack or enough exercise.
Diabetes Self-Management Education
The self-management Education of diabetes will include taking medication (Metformine) as prescribed. Jeff also has to improve on diet by reducing the amount of sugar content he takes in his meals. This means that he has to be used in taking food substances with less sugar content the regular exercise, testing of home blood glucose are part and parcel of self-management education. Therefore the self-education in this case includes practices that rae cost effective through the reduction of hospital admissions. ( Powers et al., 2017) .
References
Powers, M. A., Bardsley, J., Cypress, M., Duker, P., Funnell, M. M., Fischl, A. H., ... & Vivian, E. (2017). Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. The Diabetes Educator , 43 (1), 40-53.
Porth, C. M. (2015). Essentials of pathophysiology: Concepts of altered health states (4 th ed .). Philadelphia, PA. Wolters Kluwer Health|Lippincott Williams & Wilkins.
Zinman, B., Wanner, C., Lachin, J. M., Fitchett, D., Bluhmki, E., Hantel, S., ... & Broedl, U. C. (2015). Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. New England Journal of Medicine , 373 (22), 2117-2128.
Linde, K., Kriston, L., Rücker, G., Jamil, S., Schumann, I., Meissner, K., ... & Schneider, A. (2015). Efficacy and acceptability of pharmacological treatments for depressive disorders in primary care: systematic review and network meta-analysis. The Annals of Family Medicine , 13 (1), 69-79.
Zhao, N., Li, J., Li, L., Niu, X. Y., Jiang, M., He, X. J., ... & Lu, A. P. (2015). Molecular network-based analysis of Guizhi-Shaoyao-Zhimu decoction, a TCM herbal formula, for treatment of diabetic peripheral neuropathy. Acta Pharmacologica Sinica , 36 (6), 716.
