Apply information from the Aquifer Case Study to answer the following discussion questions:
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?
Sample Answer
Mrs. Gomez’s History That Would Be Pertinent to Her Difficulty Sleeping
The chief complaint (CC) of the patient is difficulty sleeping. Mrs. Gomez reports only being able to sleep for only a couple of hours for the last six months. She feels like she is in slow motion, feels sad at the time but denies suicidal thoughts. She has a medical history of hypertension, type II diabetes, hypercholesterolemia, and her last HgA1c. She currently lives with her daughter after the death of her husband of 30 years.
Physical Exam and Diagnostic Tools to Be Used for Mrs. Gomez
Physical examination would focus on the neck and head for thyroid abnormalities. It would also include vital signs, abdominal, cardia, HENT, and respiratory. Other tests that could be offered include CMP, TSH, and CBC to rule out other causes of fatigue, insomnia, and depressed mood. Anemia and electrolyte abnormalities may cause fatigue and insomnia. A CT scan is a diagnostic test that can be used to test vascular dementia. Additional tests would include suicide valuation.
Three Differential Diagnoses for Mrs. Gomez And Explain Why You Chose Them and The Final Diagnosis
Three differential diagnoses include depression, hypothyroidism, and Parkinson’s disease. According to Dunn and Turner (2016), hypothyroidism is associated with weight gain, fatigue, and alteration in cognition. Differential diagnosis is due to sleep disturbances experienced by the patient. Impaired sleep is usually the chief complaint of depression (Fang et al., 2019). Since the patient reports being in slow motion, she might have Parkinson’s disease. The final diagnosis is depression. The final diagnosis is depression.
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
The plan of care for the patient will be antidepressant medication therapy. The treatment of choice will be sertraline. The drug is well tolerated compared to tricyclic antidepressants, and it can be accessed in generic form (Singh & Saadabadi, 2019). Cognitive-behavioral therapy will also be included to enable the patient to deal with the loss of their spouse and their new environment. Patient education will focus on the side effects of the drug, such as diarrhea, hallucination, bleeding, tremor, and confusion (Singh & Saadabadi, 2019). The patient would be advised to stop taking herbal tea. She should also stop taking methyldopa and start amlodipine.
