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.
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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