· 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?

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· 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?

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This week, complete the Aquifer case titled “Case #3: 65-year-old female with insomnia – Mrs. Gomez”
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%.”
Question
What are common causes of insomnia in the elderly?
SUBMIT
References
Yaremchuk K. Sleep disorders in the elderly. Clin Geriatr Med. 2018 34(2):205-216. doi: 10.1016/j.cger.2018.01.008.
CONTINUE
DIAGNOSES
FINDINGS
NOTES
BOOKMARKS
Common causes of insomnia in the elderly:
1.  Environmental problems
2.  Drugs/alcohol/caffeine
3.  Sleep apnea
4.  Parasomnias: restless leg syndrome/periodic leg movements/REM sleep behavior disorder
5.  Disturbances in the sleep-wake cycle
6.  Psychiatric disorders, primarily depression and anxiety
7.  Symptomatic cardiorespiratory disease (asthma/chronic obstructive pulmonary disease/congestive heart failure)
8.  Pain or pruritus
9.  Gastroesophageal reflux disease (GERD)
10. Hyperthyroidism
11. Advanced sleep phase syndrome (ASPS)
TEACHING POINT
Common Causes of Insomnia in the Elderly
Issues that may lead to an environment that is not conducive to sleep.
·  Specific examples include: noise or uncomfortable bedding.
·  You can teach the patient sleep hygiene techniques that will increase the likelihood of a restful night’s sleep.
Question the use of prescription, over-the-counter, alternative, and recreational drugs that might be affecting sleep.

Patients should be counseled to avoid caffeine and alcohol for four to six hours before bedtime.

Sleep apnea is common in the elderly, occurring in 20% to 70% of elderly patients.

Obstruction of breathing results in frequent arousal that the patient is typically not aware of; however, a bed partner or family member may report loud snoring or cessation of breathing during sleep.

In restless leg syndrome, the patient experiences an irresistible urge to move the legs, often accompanied by uncomfortable sensations.
In periodic leg movement and REM sleep behavior disorder, the patient experiences involuntary leg movements while falling asleep and during sleep respectively.

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