How to write a Family Medicine Case Study

How to write a Family Medicine Case Study

Question 1

Mrs. Gomez is a 65-year-old female patient reporting to the clinic with complaints of difficulty sleeping. The patient is accompanied by her daughter and states that for the past six months, sleep has only occurred in 2 to 3-hour increments. She denies any discomfort like pain, snoring, sleep apnea, or breathing problems that might disturb her sleep. Further history reveals that she stays with her daughter and son-in-law after her spouse of 30 years passed away one year ago. In the past six months, Mrs. Gomez has gained 10 lbs probably related to lack of activity like before. . She denies any suicidal or thoughts of self-harm.

The patient’s past medical history is positive for hypertension, type II diabetes, and hypercholesterolemia. Her surgical history indicates she had cholecystectomy and hysterectomy done due to fibroids. Mrs. Gomez denies using any medications to address her sleeping problems. Regarding the use of medications, the patient uses Glyburide 10mg daily and Metformin 1g bid for diabetes; Methyldopa 250mg bid and Lisinopril 10mg daily for hypertension; Artovastatin 80mg daily for hypercholesterolemia, Calcium citrate with vitamin D 600mg/400 IU bid for prevention of osteoporosis, and Aspirin 81mg daily for prevention of coronary heart disease (CHD).

Insomnia is a common sleeping disorder where individuals fail to initiate or remain asleep despite the opportunity to do so. The condition is characterized by difficulty initiating sleep, difficulty maintaining sleep, frequent awakenings, or early morning awakening with difficulty returning to sleep (Patel et al., 2018). The causes of insomnia are multifactorial. For instance, women older than 45 years are 1.7 times more likely to exhibit insomnia than men (Patel et al., 2018). Smoking, alcohol use, and reduced physical activity can also contribute to insomnia. Additionally, patients with depression and anxiety disorder may face challenges with sleeping.

Question 2

The first part of the examination should focus on vital signs and focused physical examination. The patient’s vitals were taken and revealed values within the normal limits. The physical examination and review of systems also revealed unremarkable results. The geriatric depression scale was used to assess the patient and a score of 9 revealed the diagnosis of depression with the Mini-cog examination used to rule out other conditions. Other diagnostic tests used included a CBC, CMP, and TSH to evaluate electrolyte changes, anemia, and hypothyroidism that may contribute to mood changes. What I could have added in this examination is an assessment of how much Zapote tea that Mrs. Gomez takes. It is established that the fruit has effects on smooth muscles and can be used to treat insomnia, hypertension, and rheumatic pain.

Question 3

The differential diagnosis for Mrs. Gomez include:

Depression. This diagnosis is considered because of the findings from the geriatric depression scale. A score of 9 indicates that the patient is moderately depressed (American Psychological Association, 2020).

Dementia. Dementia is a syndrome that is chronic or progressive that leads to deterioration in cognitive function. The condition is characterized by losing track of time, forgetfulness, behavior changes, and loss of energy. Mrs. Gomez has problems with maintaining focus and her daughter explains that she is observed to move in slow motion. Given her age, dementia could be a potential diagnosis. However, the Mini-Cog examination findings are within the normal range ruling out the diagnosis.

Hypothyroidism. The condition is common among women of older age and manifests with symptoms like anemia, confusion, low body temperature, and loss of energy (Chaker et al., 2017). Mrs. Gomez has gained 10 lbs, feels tired, demonstrates signs of depression, and has a loss of interest that is consistent with hypothyroidism. A TSH test can help rule out this diagnosis

Final diagnosis: My final diagnosis for this patient is depression as evidenced by a GDS score of 9.

Question 4

The plan of care for the patient will involve treatment with Zoloft 25 mg daily for the management of depression (Kok & Reynolds, 2017). Health education for the patient will include exercise for weight management and avoiding junk foods. The patient should also be informed about the side effects of Zoloft like headache, sleepiness, and the need to monitor for suicidal thoughts. The follow-up plan for the patient will include a four weeks return period to assess the effectiveness of treatment.


American Psychological Association. (2020). Geriatric depression scale (GDS).

Chaker, L., Bianco, A. C., Jonklaas, J., & Peeters, R. P. (2017). Hypothyroidism. Lancet (London, England)390(10101), 1550–1562.

Kok, R. M., & Reynolds, C. F., 3rd (2017). Management of depression in older adults: A review. JAMA317(20), 2114–2122.

Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the elderly: A review. Journal of Clinical Sleep Medicine14(6), 1017–1024.

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