South Week 4 Family Medicine 65 Year Old Woman with Insomnia Case Analysis This discussion assignment provides a forum for discussing relevant topics for t

South Week 4 Family Medicine 65 Year Old Woman with Insomnia Case Analysis This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered. For this assignment, make sure you post your initial response to the Discussion Area by the due date assigned.

To support your work, use your course textbook readings and the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.

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Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Cite sources in your responses to other classmates. Complete your participation for this assignment by the end of the week.

For this assignment, you will complete a Aquifer case study based on the course objectives and weekly content. Aquifer cases emphasize core learning objectives for an evidence-based primary care curriculum. Throughout your nurse practitioner program, you will use the Aquifer case studies to promote the development of clinical reasoning through the use of ongoing assessments and diagnostic skills and to develop patient care plans that are grounded in the latest clinical guidelines and evidence-based practice.

The Aquifer assignments are highly interactive and a dynamic way to enhance your learning. Material from the Aquifer cases may be present in the quizzes, the midterm exam, and the final exam.

Learn how to access and navigate Aquifer.

This week, complete the Aquifer case titled “Family Medicine 03: 65-year-old woman with insomnia”

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? You are doing an eight-week clerkship in a family medicine practice. Christina, the medical
assistant, hands you the progress note for the next patient, which identifies the patient as Mrs.
Gomez, “a 65-year-old woman who is here today reporting that she can’t sleep.”
Dr. Lee, your preceptor, fills you in: “Mrs. Gomez has been a patient here for several years.
Difficulty sleeping is a new issue for her. Her past medical history is significant for hypertension
and diabetes. Generally, she has been doing well, although I notice that her last hemoglobin A1c
has climbed to 8.7%.”
Dr. Lee tells you, “Poor sleeping habits can also cause insomnia. Here is a handout on sleep hygiene. For
some patients, simply correcting their sleep habits by following these tips will correct their quality of
After discussing these potential causes of insomnia with Dr. Lee, you feel prepared to talk with Mrs.
Gomez. You knock on the exam room door and enter to find Mrs. Gomez, who is accompanied by her
daughter, Silvia. You introduce yourself and ask if you may ask her a few questions, to which she agrees.
“What brings you to the clinic today?”
“I’m just so tired lately. I just can’t seem to sleep.”
Tell me more about this.”
“Well, for the last six months I can’t sleep for more than a couple of hours before I wake up,”
Mrs. Gomez tells you.
On further questioning, Mrs. Gomez denies any discomfort such as pain or breathing problems
disturbing her sleep. She denies any snoring, apneic spells (a period of time during which
breathing stops or is markedly reduced), or physical restlessness during sleep. Her daughter
agrees that she has not seen these problems. She rarely consumes alcohol or caffeine.
When you ask if anything like noise or an uncomfortable sleeping environment might be
bothering her, she replies that this is not a problem – but her daughter interjects: “Yes, in fact
Mom’s waking up the rest of us, walking around and turning on the TV. My husband and I both
work. So we all need our rest. Mom came to live with us last year after Dad passed away. We’re
her only family around here and we thought we should help her.”
I’m sorry to hear about your husband.”
“Yes, we were married for 30 years. This has been a difficult time for me.”
“Do you find that you feel sad most of the
“Of course I am sad when I think about my husband and how much I miss him. But I wouldn’t
say that I’m sad most of the time.”
Silvia states, “But Mom, you spend most of your time just moping around the house.” Turning to
you she elaborates, “She seems to be in slow motion most of the time. She doesn’t even go to
church anymore. She used to go three to four times a week. She used to read all the time, and she
doesn’t do that anymore either.”
Mrs. Gomez explains, “I haven’t been reading as much as I used to because I can’t seem to focus
and I end up reading the same page over and over.” She goes on to say, “And I don’t seem to
have any energy to do anything. I’m not even able to help out around the house. I feel bad about
that; I should be helping out more. I seem to spend a lot of time just watching TV and eating
junk food.”
“Have you tried anything to help you sleep?”
“Well, I tried Tylenol PM (acetaminophen and diphenhydramine), which didn’t help and gave me
a dry mouth. I also tried zapote blanco, a kind of Mexican herbal tea. But it didn’t help me sleep
“I’m not familiar with that product, but I’ll mention it to Dr. Lee. I’m glad you brought it up. It’s
important that your doctors know about everything you are taking, whether it’s prescription
medication or not. I’m sorry nothing seems to be helping you sleep. We’ll get to the bottom of
this together.”
You turn your attention to taking Mrs. Gomez’s past medical history. You learn:
Problem list:

Type 2 diabetes
Surgical history:

Hysterectomy (due to fibroids)
For diabetes:

Glyburide (10 mg daily)
Metformin (1,000 mg bid)
For blood pressure:

Methyldopa (250 mg bid)
Lisinopril (10 mg daily)
For cholesterol:

Atorvastatin (80 mg daily)
For CHD prophylaxis:

Aspirin 81 mg daily
For osteoporosis prevention:

Calcium citrate with vitamin D (600mg/400 IU bid)
Diphenhydramine is her only over-the-counter medication, and she is taking no traditional or
herbal medications beyond the zapote tea.
Social History
She does not smoke, and drinks only small amounts of alcohol on holidays.
When you return to the exam room, after washing your hands, you perform a physical exam on
Mrs. Gomez.
Vital signs:

Heart rate: 60 beats/minute and regular
Respiratory rate: 16 breaths/minute
Blood pressure: 128/78 mm Hg
Weight: 186 pounds (up 10 pounds since last year)
Height: 64 in
Head, eyes, ears, nose and throat (HEENT): No thyromegaly, adenopathy, or masses.
Cardiac: Regular rate and rhythm, no murmur or gallops. No edema.
Respiratory: Clear to auscultation.
Abdominal: Soft, nontender, without organomegaly or masses.
Neurologic: Cranial nerves 3-12 intact. Normal strength and light touch sensation in extremities.
No tremors. Normal gait.
You locate Dr. Lee and present the case to her, expressing your concern that Mrs. Gomez is
depressed. She suggests discussing the evidence you found that Mrs. Gomez may have
You tell Dr. Lee, “Mrs. Gomez has depressed mood and seven of the nine criteria.”
Entering the room with you, Dr. Lee greets Mrs. Gomez and her daughter, and thanks them for
allowing you to interview them.
She tells Mrs. Gomez, “I understand that you’ve been having trouble sleeping – not unusual given
your recent stresses. These can also lead to feelings of depression. I’d like to look into this by
going over a short questionnaire with you.”
Dr. Lee goes over the questions on the Geriatric Depression Scale – Short Form (GDS-SF) with
Mrs. Gomez. Her score equals 9. This confirms depression, as a score of > 5 is consistent with
the diagnosis of depression.
Dr. Lee then performs a Mini-Cog exam to screen for dementia, explaining to Mrs. Gomez that
in cases like this, checking out the patient’s memory and concentration can help to rule out other
disorders and can assist in planning treatment. She scores in the normal range.
Dr. Lee concludes, “In the elderly, the chance of spontaneous remission of depression is much lower
than in younger patients, so it’s best we start some form of therapy. I agree that an SSRI and/or
psychotherapy would be a good choice for Mrs. Gomez. Also, the death of her husband and moving into
a new environment proved to be stressful for her. Cognitive therapy can help her cope with these life
“I’m glad Mrs. Gomez mentioned trying out a traditional herbal treatment,” Dr. Lee tells you,
“This is the sort of thing you don’t want to miss. Do you know anything about zapote?”
You quickly search a drug program on your PDA and an online database and identify a couple of
websites that discuss zapote and its suggested uses, but not much else.
When you re-enter the exam room, Dr. Lee sits down to talk with Mrs. Gomez, “I would like to
do a few tests to rule out any medical problem that might be causing your symptoms. But it looks
as though you may be suffering from depression, which is completely understandable given the
recent changes in your life.
“This may also explain the increases in your blood sugar: Depression takes away your energy
and motivation, so it’s hard to summon the effort to stick to a diet or even remember to take your
medication regularly.”
After discussing the options for treatment and the various SSRIs, Mrs. Gomez agrees to try
sertraline (Zoloft). Dr. Lee writes a prescription for sertraline 25 mg daily, which is well
tolerated and available in a generic form. She tells Mrs. Gomez, “Possible side effects include
headache, nausea, diarrhea, sleepiness, and (infrequently) insomnia. Because of your age and
other medical problems, I’m starting with a moderate dose, but we may increase it later if you
don’t have an adequate response.”
Dr. Lee is also worried that Mrs. Gomez’s methyldopa may be aggravating her depression, so she
substitutes amlodipine 5 mg daily. This would also be in line with current blood pressure
Next, she suggests,
You recommend Mrs. Gomez try to get some exercise, possibly walking at the local mall. She
agrees to try this. And you give Mrs. Gomez and her daughter a handout about the diagnosis of
depression and a list of community resources for people struggling with depression.
Dr. Lee reviews the plan with Mrs. Gomez and her daughter: “We will order the blood tests to
make sure there are no other medical conditions causing your symptoms. I will order a
hemoglobin A1c to see how your diabetes is doing. We may need to adjust your diabetes
“Do you have any other questions?” Dr. Lee asks Mrs. Gomez and her daughter. They shake
their heads no.
Dr. Lee then concludes the visit: “It will probably take four to six weeks before the medication is
fully effective, but it is best if I see you before then – let’s say in two weeks – to monitor your
progress and discuss any problems or side effects; we will also review your tests and see if
anything else needs to be done. Please feel free to call or come in sooner than that if you have
concerns, feel worse, or experience side effects that prevent you from continuing to take your

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