Subjective: Ann is a 33-year-old married black

Subjective: Ann is a 33-year-old married black female who works for a local newspaper and presents to the FNP office with complaints of problems sleeping, fatigue, and difficulty “getting going.” She reports intermittent awakening and usually having a lot of trouble waking up in the morning. She states she lies in bed in the morning and can’t get up. She reports difficulty concentrating during the day and that she often loses her thoughts and has difficulty at work due to this. Recently it takes her longer to complete her work. She fears that if she doesn’t start sleeping soon she will lose her job because she is not performing at her usual level; in addition, she is tire and irritable and is not getting along as well as normal with colleagues or family members. She said she feels tense all the time ad has difficulty getting her job fears out of her mind. These symptoms have been increasingly difficulty in the past 2 months, but present to a lesser degree over the past 8 months since she changed jobs. It is typical for her to wake up more than once during the night now; however, she never struggled to get back to sleep previously. Past medical history: She reports having similar sleep problems after her college graduation wasn’t sure what to do with her life. The sleep problems and anxiety resolved after she found a part-time job and then was hired by the company full-time. She denies prior history of psychiatric disorder or treatment. She has a history of gastroesophageal reflux disease. She has no other prior medical problems. She had a 30-lb weight gain after her last pregnancy, which she has been unable to lose. She has never had surgery. Family History: She has a family history of ischemic heart disease in her father and uncles, and breast cancer in a maternal aunt. Social History: She denies smoking, but drinks 1-2 glasses of wine with dinner. She is married and has 2 children, ages 4 and 7. She has been more irritable with her family recently. They live in a large suburban town in a condominium complex. Her husband works at a local factory on the evening shift. She works day at a local newspaper. She has a few friends at work and a few friends from college who are not local. She sees friends less since having children. Her social life surrounds the activities of her children and husband. She has a degree in graphic arts, likes music, and likes reading. Medications: Pantoprazole, 40 mg PO QD Allergies: NKDA Objective: Ann appears restless and has dark circles under her eyes. Vital signs: BP 118/72, pulse 94; temperature: 98.6 Height: 5 ft 4 inches weight; 170 Critical Thinking Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? CBC _ TSH_ CMP_ Lipid panel_ LFTs_ What are your next steps in assessment and determining a diagnosis? What is the most likely differential diagnosis and why? _Generalized anxiety _Major depressive disorder _Hyperthyroidism What is the plan of treatment? What is the plan for follow-care? Are there any referrals at this time? Does the patient’s psychosocial history impact how you might treat this patient? What if the patient were over age 65 or under age 13? What if the patient lived in a rural, isolated setting? SCIENCE HEALTH SCIENCE NURSING NUR MISC

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