Patient History
Mrs. Gomez is a 65-year-old woman, and her chief complaint is insomnia, which has been ongoing for several years. Her recent gain of 10 pounds, slow-motion feeling, and inability to focus is also essential. Her medical history includes hypercholesterolemia, type 2 diabetes, hypertension, cholecystectomy, and hysterectomy.
She takes medications: glyburide, metformin, methyldopa, lisinopril, atorvastatin, aspirin, calcium citrate with vitamin D, diphenhydramine, and Zapote tea. Her last hemoglobin A1c was 8.7%. She has lived with her daughter and son-in-law since her spouse passed away.
Physical Examination and Diagnostic Tools
General examination, including vital signs, assesses overall appearance. A neurological exam should be performed to evaluate cognitive status. A Mini-Cog test may be administered to evaluate cognitive function and screen for dementia. A musculoskeletal exam would be performed to identify joint or muscle problems.
Differential Diagnoses for Patient Condition
Diagnostic tools that can be used to aid in diagnosis include laboratory tests, a complete blood count (CBC), a comprehensive metabolic panel (CMP), and a thyroid-stimulating hormone (TSH). Geriatric Depression Scale – Short Form (GDS-SF) be administered to assess mood and detect depression. Mrs. Gomez may undergo a sleep study to evaluate her sleep quality. Imaging studies such as a CT or MRI scan may be ordered.
The final diagnosis is that the patient is experiencing depression. The Geriatric Depression Scale – Short Form (GDS-SF) score of 9, above the cutoff for depression, supports this diagnosis. The patient’s symptoms, including a persistent low mood, lack of interest in activities, and changes in sleep patterns, are consistent with depression. (Gold et al., 2020)
The other differential diagnoses, dementia, and hypothyroidism, were ruled out based on the Mini-Cog exam and the need to check the thyroid stimulating hormone (TSH) level, respectively. Dementia was possible. Mrs. Gomez had difficulty focusing and lost interest in once-enjoyable activities.
Hypothyroidism could be a differential diagnosis since Mrs. Gomez has gained weight, is lethargic, and has a decreased ability to focus. Vestibular migraine is a type of migraine headache that is associated with vertigo and dizziness. The fact that Mrs. Gomez had a history of migraines makes this a possibility.
Plan of Care: Drug Therapy, Treatments, Patient Education, and Follow-Up
The treatment program for Mrs. Gomez included medication, counseling, and follow-up. She will receive 25 mg of sertraline every day. She will be instructed to take the drug as prescribed for at least 9 to 12 months, with dose adjustments as necessary. Additionally, Mrs. Gomez will receive instruction on creating a sleep regimen, practicing excellent sleep hygiene, and avoiding coffee and alcohol. She will be asked to record any weakness; these might be symptoms of hyponatremia.
References
Gold, S. M., Köhler-Forsberg, O., Moss-Morris, R., Mehnert, A., Miranda, J. J., Bullinger, M., & Otte, C. (2020). Comorbid depression in medical diseases. Nature Reviews Disease Primers, 6(1), 69. Web.