Discussion Question 1
Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.
Discussion Question 2
Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.
Discussion Question 3
Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text.
Discussion Question 4
Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.
Discussion Question 5
Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client.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 female 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?
The suggested answer is shown below.
Letter Count: 81/1000
SUBMIT
Answer Comment
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
1. 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.
2. The use of prescription, over-the-counter, alternative, and recreational drugs might affect sleep.
· Patients should be counseled to avoid caffeine and alcohol for four to six hours before bedtime.

3. 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.
4. In restless leg syndrome, the patient experiences an irresistible urge to move the legs, often accompanied by uncomfortable sensations.
5. In periodic leg movement and REM sleep behavior disorder, the patient experiences involuntary leg movements while falling asleep and during sleep respectively.
· As for sleep apnea, the sleeper is often unaware of these behaviors and a bed partner or family member may need to be asked about these movements.
6. Disturbances in the sleep-wake cycle include jet lag and shift work.
7. Patients with depression and anxiety commonly present with insomnia.
· Any patient presenting with insomnia should be screened for these disorders.
8. Patients with shortness of breath due to cardiorespiratory disorders often report that these symptoms keep them awake.
9. Pain or pruritus may keep patients awake at night.
10. Those with GERD may report heartburn, throat pain, or breathing problems.
· These patient




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