- Discuss the Mrs. Gomez’s history that would be pertinent to her difficulty sleeping. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.
- Describe the physical exam and diagnostic tools to be used for Mrs. Gomez. Are there any additional you would have liked to be included that were not?
- Please list 3 differential diagnoses for Mrs. Gomez and explain why you chose them. What was your final diagnosis and how did you make the determination?
- What plan of care will Mrs. Gomez be given at this visit, include drug therapy and treatments; what is the patient education and follow-up?
- History:
- Chief Complaint: Mrs. Gomez presents with difficulty sleeping.
- HPI (History of Present Illness): She reports that her sleep problems have been ongoing for the past six months. She describes difficulty falling asleep, frequent awakenings during the night, and difficulty getting back to sleep once awakened. She also complains of daytime fatigue, irritability, and difficulty concentrating.
- Social History: Mrs. Gomez is a 60-year-old Hispanic female. She is married and lives with her husband. She is retired and reports no significant work-related stressors. She denies the use of caffeine or alcohol close to bedtime. She does not smoke.
- Family History: There is no significant family history of sleep disorders or psychiatric conditions.
- Past Medical History: Mrs. Gomez has a history of hypertension and is on medication (lisinopril) for it. She has no known history of psychiatric disorders.
- Physical Exam and Diagnostic Tools:
- A physical exam would include checking her blood pressure, heart rate, and respiratory rate.
- Diagnostic tools may include:
- Blood tests to rule out underlying medical conditions (e.g., thyroid function, glucose levels).
- Polysomnography or a sleep study to evaluate her sleep patterns and diagnose any sleep disorders.
- A mental health assessment to identify any underlying anxiety or mood disorders contributing to her sleep problems.
- Additional information that could be useful includes dietary habits, exercise routine, and a more detailed sleep diary.
- Differential Diagnoses:
- 1. Insomnia Disorder: Given the prolonged duration of sleep difficulties, it’s possible Mrs. Gomez has primary insomnia. This diagnosis would require further evaluation through a sleep study to confirm.
- 2. Sleep Apnea: Sleep apnea could be considered due to her age, and common symptoms like frequent awakenings. A sleep study would help diagnose or rule out this condition.
- 3. Anxiety or Mood Disorder: Mrs. Gomez’s daytime symptoms of irritability and difficulty concentrating may be indicative of an underlying anxiety or mood disorder. This could be contributing to her sleep problems.
- Final Diagnosis:
- Pending the results of diagnostic tests, the final diagnosis could be Insomnia Disorder, Sleep Apnea, or an underlying Anxiety or Mood Disorder.
- Plan of Care:
- Insomnia: If the diagnosis is insomnia, non-pharmacological approaches such as cognitive-behavioral therapy for insomnia (CBT-I) may be recommended. Medication, such as a short-term use of a hypnotic like zolpidem, might be considered if necessary.
- Sleep Apnea: Continuous positive airway pressure (CPAP) therapy may be recommended if sleep apnea is diagnosed.
- Anxiety/Mood Disorder: If an anxiety or mood disorder is diagnosed, psychotherapy and/or medication may be suggested.
- Patient Education: Mrs. Gomez should receive education on sleep hygiene practices and any prescribed medications or therapies.
- Follow-up: She should schedule a follow-up visit to monitor progress, adjust treatment as necessary, and address any concerns or side effects. Behavioral interventions like CBT-I may require multiple sessions.
This plan of care should be tailored to Mrs. Gomez’s specific diagnosis, and her healthcare provider would make the final determination based on the results of diagnostic tests and her individual needs.