Treatment for a Patient With a Common Condition

Treatment for a Patient With a Common Condition

Treatment for a Patient With a Common Condition

The case study that is offered shows a 75-year-old widow who complains primarily of sleeplessness. The patient states that the loss of her spouse around 10 months ago has caused her depressive symptoms and sleeping patterns to deteriorate. Before her husband’s death, she denied having a history of depression. The patient admits having had HTN, DM, and MDD in the past. She currently takes Metformin 500 mg BID, Januvia 100 mg daily, Losartan 100 mg daily, HCTZ 25 mg daily, and Sertraline 100 mg daily to treat these conditions. Following a mental health assessment, the patient showed the right sense of person, place, and time. She, though, denies having suicidal thoughts. She mentions that she typically sees her primary care doctor once or twice a year. Her BMI revealed high blood pressure and an obesity-indicating BMI of 34.37. The purpose of this discussion is to evaluate the patient mentioned above and to determine the best course of therapy.

Questions for the Patient

1. What brought you here today? The patient can provide as much information as feasible on her health state concerning the symptoms that are now being experienced by answering this open-ended question (Patel et al., 2018).
2. Do you use tobacco, alcohol, caffeine, or any other drugs? Examining all potential reasons, such as drug usage, is crucial because sleeplessness is the patient’s primary complaint (Patel et al., 2018). Alcohol, cigarettes, and caffeine are examples of recreational substances that have been linked to an increased risk of sleeplessness.
3. What time do you often go to sleep, and how long does it typically take you to go off to sleep? To examine the patient’s sleeping habits and gauge how severe their insomnia is, this inquiry is necessary. The patient’s answer to this question will also influence the course of therapy that is chosen (Patel et al., 2018).

People to Question for Further Assessment of the Patients Situation

            For a more thorough assessment of the patient’s state, data from close family members, such as her children, who can characterize the nature of her illness at home, must be gathered. “Does the patient doze off during the day when completing ordinary tasks?” is an example of an inquiry that should be directed to the patient’s children. “Does the patient snore loudly or cease breathing while sleeping?” The first question will assist assess how much the patient’s problem is harming her quality of life, while the second question will help determine connected symptoms caused by the patient’s insomnia (Patel et al., 2018). The patient’s caregiver should also provide information on the patient’s sleeping state and surrounding environment to assess whether they are related to her lack of sleep. “Is the patient’s sleeping environment suitable to sleep in terms of the breath, light temperature, and interruptions?” is an example of a question made to the caregiver.

Physical Exams, and Diagnostic Tests

To develop a clear diagnosis, the examination and evaluation of insomnia rely heavily on the information supplied by the patient. When the origin of the insomnia is unknown, a physical examination is undertaken to determine whether the patient’s symptoms are related to an underlying medical issue (Madari et al., 2021). The physician may need to request a blood test to evaluate whether the patient’s sleeplessness is caused by thyroid issues or another ailment. Diagnostic tests, such as the Hamilton Anxiety Rating Scale (HAM-A) and Hamilton Rating Scale for Depression (HAM-D), are critical in establishing the severity of a patient’s symptoms, particularly when insomnia is linked with anxiety or depression. The findings of this test will aid in choosing the patient’s ideal course of therapy. The severity of the patient’s insomnia and related symptoms will also be assessed using actigraphy, polysomnography, daytime multiple sleep latency testing (MSLT), sleep diaries, and other methods (Abad, & Guilleminault, 2018). Last but not least, genetic testing, such as FFI tests, will assist in the diagnosis by revealing whether the client has a family history of insomnia.

Differential Diagnosis

The three primary differential diagnoses based on the presented patient’s subjective and objective data are generalized anxiety disorder, major depressive disorder (MDD), and post-traumatic stress disorder. MDD is the most likely of the three diagnose