Family and Past medical history
Family and Past medical history
Discussion #1
Discuss 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.
Mrs. Gomez is a sixty-five-year-old female with the chief complaint of “can’t seem to sleep”. She reports to the healthcare provider that for the past six months, sleep has only occurred in 2-3-hour increments, each night. According to her daughter, she no longer attends church or reads, which was once her favorite hobbies. The patient admits to feeling guilty for the change in her behavior and mood and for no longer helping her daughter with housework. Mrs. Gomez states “I don’t have the energy to do anything”. Lack of concentration has also become a problem for the patient, and she attributes this problem to the reason she no longer reads. Her appetite has changed in that she mostly eats unhealthy foods now, while watching television. Sylvia, her daughter states that it seems that her mother is moving in “slow motion”. Lastly, the patient admits to feeling sad but states that she would never be able to harm herself due to religious reasons.
Mrs. Gomez’s husband of thirty-years passed away last year, and she has since relocated to her daughter’s home. She denies a history of smoking but admits to having alcoholic beverages recreationally. Past medical history includes hypertension, hypercholesterolemia, and diabetes. Home medications include Glyburide 10mg per day, Metformin 1000mg BID, Methyldopa 250mg BID, Lisinopril 10mg per day, Atorvastatin 80mg per day, Aspirin 81 mg daily, and Calcium citrate with Vitamin D 600mg/400 IU BID. The patient also admits to using Diphenhydramine and zapote tea.
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?
The SIG E CAPS mnemonic was used to assess Mrs. Gomez for depression and the results are expressed above. Also, the Geriatric Depression Scale aided the health care providers in making a diagnosis, and the Mini-Cog examination helped rule out other conditions. A CBC, CMP and TSH were collected on Mrs. Gomez to evaluate for electrolyte abnormalities, anemia or other illnesses that could be causing her mood changes. TSH evaluation should always be considered due to the link between hypothyroidism and depression, as well as, other cognitive impairments (Tayde et al., 2017). On assessment, the patient’s vital signs are within normal range, and the physical examination is unremarkable. With a ten-pound increase in weight from last year and the report of fatigue and sadness, as a practitioner, focus should also be placed on the patient’s skin and hair. Is the patient’s skin dry or does her hair appear to be brittle? Is there edema noted in the hands or eyelids (Buttaro et al., 2017).
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?
Hypothyroidism E03.9: This condition is common among women, especially those of older age. Symptoms often present in this group as tiredness and cognitive delay (Ingoe et al., 2018). The objective finding of weight gain and subjective criteria of loss of focus, decrease in enjoyment, and tiredness provides suspicion for this ailment. Acquiring a TSH level in imperative.
Bereavement Z63.4: The patient recently experienced the loss of her husband of thirty years. Her life has been turned upside-down, so to speak, by no longer having her life-long partner and having to move from her home. When older adults experience the loss of a spouse, it is often difficult for him or her to manage everyday life as they once had. This often leads to depression (Bratt et al., 2017).
Dementia F03.90: This diagnosis should be considered due to patient’s age and the report of inability to focus and the observation of moving in “slow motion” by family members.
Depression F32.9: Mrs. Gomez admits to feeling a sense of sadness, especially within the last six months. Having to move in with her daughter has taken away some of her independence. She reports inability to remain asleep at night, lack of energy, failure to focus, loss of interest in hobbies and lack of exercise. Due to the patient presentation, Geriatric Depression Score of 9, and positive response to mood stabilizer (once compliant), the final diagnosis of depression is made.
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?
