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.
For the past six months, Mrs. Gomez’s husband passed away and she moved in with her daughter. She
has been having trouble staying asleep for more than a couple hours a night and feels tired all the time.
She has no pain or breathing problems while sleeping. She does not snore, have apneic periods, or have
physical restlessness during sleep. She does not consume caffeine and rarely consumes alcohol. She
wakes up and walks around and turns the t.v. on at night. She seems disinterested in things she used to
enjoy doing, and she mopes around the house a lot, is unable to focus, has little energy, and seems to be
in slow motion most of the time. She says she mostly lays around the house and eats junk food. She
drinks a Mexican herbal tea to help her sleep. She has a medical history of hypercholesterolemia, type 2
diabetes, and hypertension. She has a surgical history of cholecystectomy, and hysterectomy due to
fibroids. She is currently taking Glyburide (10 mg daily), Metformin (1,000 mg bid), Lisinopril (10 mg
daily), Propranolol (40 mg po bid), Atorvastatin (80 mg daily), Aspirin 81 mg daily, and Calcium citrate
with vitamin D (600mg/400 IU bid). She has gained about 10 pounds in the past year.
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?
The physical exam included a review of her symptoms, and has a normal physical exam. A suicide
assessment was also included. She was positive for seven of the nine major depressive diagnostic
criteria and was screened on the geriatric depression scale. She was found to have a scale of 9, which
indicates depression. She was also screened for dementia using the mini-cog exam, but was found to be
in the normal range. She was also given blood tests including a complete metabolic panel, thyroid
screening, and a complete blood count to rule out any medical problems. I feel like the exam and
diagnostic tools were thorough and prompt so it did not require multiple visits. The diagnosis was
prompt and accurate.
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?
The three-differential diagnosis included hypothyroidism, Parkinson’s Disease, and dementia.
Hypothyroidism can cause depression-like symptoms until the thyroid levels are returned to normal,
however, her TSH blood tests were normal. Parkinson’s Disease also causes depressive symptoms, she
did not have tremors or rigids muscles. Dementia was also a differential diagnosis because patients with
dementia can be slow, confused, or forgetful, however, when Mrs. Gomez took the mini-cog test for
dementia, she came up negative. The final differential diagnosis would have to be depression.
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?
The plan of care for Mrs. Gomez would be placing Mrs. Gomez on Sertraline - a selective serotonergic
reuptake inhibitor (SSRI), educating her to begin cognitive-behavioral therapy, and beginning an exercise
program, such as mall-walking. It’s very important to thoroughly assess her suicidal ideations. It is very
important to educate Mrs. Gomez on the importance of adhering to her medications even if she doesn’t
feel better right away. Teaching her the side effects of the Zoloft is important as well as the ability to
obtain the generic form of the medication so it is easier for her to afford and so she knows what to
complaint, HPI, Social, Family and Past medical history that would be important to know.
For the past six months, Mrs. Gomez’s husband passed away and she moved in with her daughter. She
has been having trouble staying asleep for more than a couple hours a night and feels tired all the time.
She has no pain or breathing problems while sleeping. She does not snore, have apneic periods, or have
physical restlessness during sleep. She does not consume caffeine and rarely consumes alcohol. She
wakes up and walks around and turns the t.v. on at night. She seems disinterested in things she used to
enjoy doing, and she mopes around the house a lot, is unable to focus, has little energy, and seems to be
in slow motion most of the time. She says she mostly lays around the house and eats junk food. She
drinks a Mexican herbal tea to help her sleep. She has a medical history of hypercholesterolemia, type 2
diabetes, and hypertension. She has a surgical history of cholecystectomy, and hysterectomy due to
fibroids. She is currently taking Glyburide (10 mg daily), Metformin (1,000 mg bid), Lisinopril (10 mg
daily), Propranolol (40 mg po bid), Atorvastatin (80 mg daily), Aspirin 81 mg daily, and Calcium citrate
with vitamin D (600mg/400 IU bid). She has gained about 10 pounds in the past year.
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?
The physical exam included a review of her symptoms, and has a normal physical exam. A suicide
assessment was also included. She was positive for seven of the nine major depressive diagnostic
criteria and was screened on the geriatric depression scale. She was found to have a scale of 9, which
indicates depression. She was also screened for dementia using the mini-cog exam, but was found to be
in the normal range. She was also given blood tests including a complete metabolic panel, thyroid
screening, and a complete blood count to rule out any medical problems. I feel like the exam and
diagnostic tools were thorough and prompt so it did not require multiple visits. The diagnosis was
prompt and accurate.
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?
The three-differential diagnosis included hypothyroidism, Parkinson’s Disease, and dementia.
Hypothyroidism can cause depression-like symptoms until the thyroid levels are returned to normal,
however, her TSH blood tests were normal. Parkinson’s Disease also causes depressive symptoms, she
did not have tremors or rigids muscles. Dementia was also a differential diagnosis because patients with
dementia can be slow, confused, or forgetful, however, when Mrs. Gomez took the mini-cog test for
dementia, she came up negative. The final differential diagnosis would have to be depression.
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?
The plan of care for Mrs. Gomez would be placing Mrs. Gomez on Sertraline - a selective serotonergic
reuptake inhibitor (SSRI), educating her to begin cognitive-behavioral therapy, and beginning an exercise
program, such as mall-walking. It’s very important to thoroughly assess her suicidal ideations. It is very
important to educate Mrs. Gomez on the importance of adhering to her medications even if she doesn’t
feel better right away. Teaching her the side effects of the Zoloft is important as well as the ability to
obtain the generic form of the medication so it is easier for her to afford and so she knows what to
