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First Diagnosis : Insomnia

Diagnostics:

Insomnia can sometimes be a difficult diagnosis to treat in that there can be many factors causing the sleep disturbances. One thing the patient can do is begin a diary regarding sleep habits, alcohol use, and daily activities that may be affecting his sleep. Insomnia isquite common and can be associated with marked impairment in function and quality of life, psychiatric and physical morbidity, and accidents (Krystal et al., 2019). The clinical diagnosis of insomnia is based on the complaint of trouble falling asleep, trouble staying asleep, or early morning awakening, and resultant daytime dysfunction.

Therapeutics:

Changing one’s sleep habits and addressing any issues that may be associated with insomnia, such as stress, medical conditions or medications, can restore restful sleep for many people. If these measures don’t work, we may recommend cognitive behavioral therapy, medications or both, to help improve relaxation and sleep (Insomnia – Diagnosis and Treatment – Mayo Clinic, 2020). OTC medications like Melatonin can be tried first before using stronger prescriptions they may come along with adverse reactions. Melatonin does not develop tolerance, dependence, or effects of hang-over and it has minimal side effects. It is important to have the right conditions to ensure proper sleep. While someone with true insomnia will not be effectively treated by simply providing a dark, quiet environment, the clinician â€“ in order to confirm the diagnosis â€“ must ensure that poor sleep is not due to poor sleep conditions.

Education:

The patient requires education on alcohol due to alcohol disrupting sleep through multiple mechanisms, such as disrupting electrophysiologic sleep architecture, triggering insomnia, and contributing to abnormalities of circadian rhythms and short sleep duration (He et al., 2019). Insomnia is not solely a symptom of other mental disorders as was once thought. If insomnia is sufficiently severe to warrant independent clinical attention, it should be recognized as a separate, comorbid disorder that is treated as such.

Consultation/Collaboration: A collaborative care model for managing patients’ sleep complaints can take place in a primary care setting. Communication between sleep specialist and PCP, and demonstrated a high rate of positive outcomes.

Second Diagnosis: Obesity

Diagnostics:The initial assessment for obesity is checking the BMI index. Patients with obesity Fasting glucose, Lipids, Liver enzymes, A1C, and Thyroid Screening.

Therapeutics:Obesity management starts with lifestyle modification in nutrition, and physical activity, in addition to the use of medications. Family history, lifestyle, and psychological factors all function in propensity for obesity. The likelihood of becoming obese can be affected by nature and nurture, enhanced by family genetics (Lin, 2021).

Education:Patients with obesity require lifestyle modification in terms of nutrition and physical activities to prevent health complications. Patients need education on a low-calorie diet that includes fruits and vegetables, reducing high cholesterol, and processed foods with high sugar levels. The pathologic enlargement of fat cells will alter the nutrient signals responsible for obesity. Food sources and quality of nutrients matter more than their quantities in the diet for weight control, and also for disease prevention. More and more etiologies or defects that lead to obesity can be identified under the background of struggle between nurture and nature, genetic and epigenetic, environmental and microenvironment (Lin, 2022).

Consultation/Collaboration:

The patient may benefit from a dietitian consult to come up with a better diet and meal plan moving forward.

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