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?
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%.”
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