Week 4 Discussion advance nursing I have attached the case stud to this file  Please answer the questions below using the case stud that is attached. Disc

Week 4 Discussion advance nursing I have attached the case stud to this file  Please answer the questions below using the case stud that is attached.

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 assessment 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?

use references in apa style You are doing an eight-week clerkship in a family medicine practice. You review the EMR (electronic medical record) for the next patient, which identifies the patient as Mrs. Gomez, “a 65-year-old female 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%.”

common causes of insomnia in the elderly

1. Environmental problems

2. Drugs/alcohol/caffeine

3. Sleep apnea

4. Parasomnias: restless leg syndrome/periodic leg movements/REM sleep behavior disorder

5. Disturbances in the sleep-wake cycle

6. Psychiatric disorders, primarily depression and anxiety

7. Symptomatic cardiorespiratory disease (asthma/chronic obstructive pulmonary disease/congestive heart failure)

8. Pain or pruritus

9. Gastroesophageal reflux disease (GERD)

10. Hyperthyroidism

11. Advanced sleep phase syndrome (ASPS)

Dr. Lee tells you, “Poor sleeping habits can also cause insomnia. Here are some helpful tips to share with patients on sleep hygiene. For some patients, simply correcting their sleep habits by following these tips will correct their quality of sleep.”

Which treatments are recommended in the elderly?

Of the behavioral treatments, many of which may be of some assistance in the elderly, only sleep restriction/sleep compression therapy and multi-component cognitive-behavioral therapy have met evidence-based criteria for efficacy.

Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I is recommended as the first choice for most patients with insomnia. CBT-I combines behavioral treatments, resulting in improvements lasting up to two years. Recent guidelines recommend CBT-I as the first-line therapy for insomnia in adults. Examples include:Sleep restriction therapy, Relaxation therapy.

After discussing these potential causes of insomnia with Dr. Lee, you feel prepared to talk with Mrs. Gomez. You knock on the exam room door and enter to find Mrs. Gomez, who is accompanied by her daughter, Silvia. You introduce yourself and ask if you may ask her a few questions, to which she agrees.

What brings you to the clinic today?”

“I’m just so tired lately. I just can’t seem to sleep.”

“Tell me more about this.”

“Well, for the last six months I can’t sleep for more than a couple of hours before I wake up,” Mrs. Gomez tells you.

On further questioning, Mrs. Gomez reports no discomfort such as pain or breathing problems disturbing her sleep. She reports no snoring, apneic spells (a period of time during which breathing stops or is markedly reduced), or physical restlessness during sleep. Her daughter agrees that she has not seen these problems. She rarely consumes alcohol or caffeine.

When you ask if anything like noise or an uncomfortable sleeping environment might be bothering her, she replies that this is not a problem – but her daughter interjects: “Yes, in fact Mom’s waking up the rest of us, walking around and turning on the TV. My husband and I both work. So we all need our rest. Mom came to live with us last year after Dad passed away. We’re her only family around here and we thought we should help her.”

You tell Mrs. Gomez,

“I’m sorry to hear about your husband.”

“Yes, we were married for 30 years. This has been a difficult time for me.”

“Do you find that you feel sad most of the time?”

“Of course I am sad when I think about my husband and how much I miss him. But I wouldn’t say that I’m sad most of the time.”

Silvia states, “But Mom, you spend most of your time just moping around the house.” Turning to you she elaborates, “She seems to be in slow motion most of the time. She doesn’t even go to church anymore. She used to go three to four times a week. She used to read all the time, and she doesn’t do that anymore either.”

Mrs. Gomez explains, “I haven’t been reading as much as I used to because I can’t seem to focus and I end up reading the same page over and over.” She goes on to say, “And I don’t seem to have any energy to do anything. I’m not even able to help out around the house. I feel bad about that; I should be helping out more. I seem to spend a lot of time just watching TV and eating junk food.”

You ask,

“Have you tried anything to help you sleep?”

“Well, I tried Tylenol PM (acetaminophen and diphenhydramine), which didn’t help and gave me a dry mouth. I also tried zapote blanco, a kind of Mexican herbal tea. But it didn’t help me sleep either.”

“I’m not familiar with that product, but I’ll mention it to Dr. Lee. I’m glad you brought it up. It’s important that your doctors know about everything you are taking, whether it’s prescription medication or not. I’m sorry nothing seems to be helping you sleep. We’ll get to the bottom of this together.”

You turn your attention to taking Mrs. Gomez’s past medical history. You learn:

Problem list:

· Hypercholesterolemia

· Type 2 diabetes

· Hypertension

Surgical history:

· Cholecystectomy

· Hysterectomy (due to fibroids)


For diabetes:

· Glyburide (10 mg daily)

· Metformin (1,000 mg bid)

For blood pressure:

· Methyldopa (250 mg bid)

· Lisinopril (10 mg daily)

For cholesterol:

· Atorvastatin (80 mg daily)

For CHD prophylaxis:

· Aspirin (81 mg daily)

For osteoporosis prevention:

· Calcium citrate with vitamin D (600mg/400 IU bid)

Diphenhydramine is her only over-the-counter medication, and she is taking no traditional or herbal medications beyond the zapote tea.

Social History

She does not smoke, and drinks only small amounts of alcohol on holidays.

Given what you have heard from Mrs. Gomez and her daughter, especially

· Her inability to focus

· Her lack of energy

· The sense that she is in slow motion

· She has stopped doing activities she previously enjoyed

You are concerned that her insomnia may be due to depression. Depression may stem from environmental stressors such as her husband’s death and her loss of independence along with a primary neurochemical imbalance. Her depression also could be caused by another medical condition.

Which of the following medical conditions is associated with depression?



Parkinson disease

Keeping in mind the disorders associated with depression, you elicit a review of systems from Mrs. Gomez to help discover what these indicate regarding her underlying illness.

Constitutional: Mrs. Gomez has gained about 10 lbs in the last six months. She reports no fevers or dizziness. This makes you less concerned about cancer or other systemic illness.

Respiratory: No shortness of breath, making cardio-respiratory disease less likely.

Cardiac: No chest pains, palpitations or edema, decreasing the likelihood of cardiovascular disease.

Gastrointestinal: No nausea, changes in bowel habits, hematochezia or melena. This makes you less concerned about gastrointestinal cancer or occult blood loss leading to anemia.

Endocrinologic: No polydipsia or polyuria, decreasing the likelihood of poorly controlled diabetes.

Neurologic: No acute neurologic changes or tremors. Her daughter confirms that her mother has been alert, oriented, and has had no episodes of confusion. So you are now less concerned about cerebral infarction, intracranial tumors, multiple sclerosis, and Parkinson disease.

Urologic: Normally urinates one to two times at night.

When you return to the exam room, after washing your hands, you perform a physical exam on Mrs. Gomez.

Vital signs:

· Pulse is 60 beats/minute and regular

· Respiratory rate is 16 breaths/minute

· Blood pressure is 128/78 mm Hg

· Weight is 84 kg (186 lbs (up 10 lbs since last year))

· Height is 163 cm (64 in)

Head, eyes, ears, nose and throat (HEENT): No thyromegaly, adenopathy, or masses.

Cardiac: Regular rate and rhythm, no murmur or gallops. No edema.

Respiratory: Clear to auscultation.

Abdominal: Soft, nontender, without organomegaly or masses.

Neurologic: Cranial nerves 3-12 intact. Normal strength and light touch sensation in extremities. No tremors. Normal gait.

Once you have completed your review of systems, you excuse yourself from the room for a moment while Mrs. Gomez changes into a gown.

You are afraid your next question may upset Mrs. Gomez, but you know it is important to ask: “Mrs. Gomez, I have one more question: When people are down, sometimes they wish they would fall asleep and never wake up.

“Have you had any thoughts of dying or causing harm to yourself?”

“Well, it has been hard and I would like to see my husband, but I could never hurt myself because of my religion,” she tells you.

“Okay, thank you for your openness with me,” you tell Mrs. Gomez. “I would like to bring in Dr. Lee so she can also perform a physical exam before you get dressed. We’ll be back in just a minute. Do you have any questions for me before I go?”

Mrs. Gomez indicates she doesn’t have any concerns, so you exit the room.

What factors increase a patient’s risk for completed suicide?

Having a previous suicide attempt.

Having served in the military.

 Male sex.

Older age

You locate Dr. Lee and present the case to her, expressing your concern that Mrs. Gomez is depressed. She suggests discussing the evidence you found that Mrs. Gomez may have depression.

You tell Dr. Lee, “Mrs. Gomez has a depressed mood and seven of the nine criteria.”


Major Depression Diagnostic Criteria

· For a diagnosis of major depression, the patient must have at least five of the following nine criteria for a minimum of two weeks.

· A least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure.

Depressed Mood

(The eight remaining criteria can be remembered using the mnemonic SIG E CAPS):

Sleep: Insomnia or hypersomnia nearly every day.

Interest (loss of): Anhedonia (loss of interest or enjoyment) in usual activities.

Guilt: Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).

Energy (decreased): Fatigue or loss of energy nearly every day.

Concentration (decreased, or crying): Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).

Appetite (increased or decreased): or significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month).

Psychomotor retardation: Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).

Suicidal ideation: Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

“You seem to have established that Mrs. Gomez meets the criteria for a major clinical depression,” says Dr. Lee, and goes on to explain:


Major Depressive Disorder versus Bereavement

The presence of certain symptoms that are not characteristic of a “normal” grief reaction may be helpful in differentiating bereavement from a Major Depressive Episode. The table below adapted from the DSM V discusses some potential differences:

Major Depressive Episode

Bereavement (Grief)

Persistent depressed mood and inability to anticipate happiness or pleasure

Feelings of emptiness and loss

Depression persistent, not tied to specific thoughts or preoccupations

Depressed feelings often decrease in intensity over days to weeks and occur in waves, associated with thoughts of the deceased

Pervasive unhappiness and misery

Grief may be accompanied by positive emotions and humor

Self-critical or pessimistic ruminations

Preoccupation with thoughts and memories of the deceased

Feelings of worthlessness and self-loathing

Self-esteem is generally preserved. May be self-deprecating—feeling they should have done more or told the deceased how much he or she was loved

Suicidal ideation because of feeling worthless, undeserving of life, or unable to cope with the pain of depression

Individual thinks about death and dying, generally focused on the deceased and possibly about joining the deceased


Risk factors for Late-life depression

Risk factors for late-life depression include:

· Female sex

· Social isolation

· Widowed, divorced, or separated marital status

· Lower socioeconomic status

· Comorbid general medical conditions, e.g. stroke, heart disease and cancer

· Uncontrolled pain

· Insomnia

· Functional impairment

· Cognitive impairment


Depression in the Elderly

Depression is a very serious disease in the elderly:

· Depression increases the risk of disabilities in mobility and the activities of daily living by about 70% over the course of six years.

· Alcohol and drug abuse are very common comorbidities complicating depression.

· Completed suicide is more common in older depressed patients.

You express to Dr. Lee your concern that by asking about suicide you may have made the situation worse.

Dr. Lee reassures you: “Many people worry that bringing up the subject of suicide will cause the patient to commit suicide. On the contrary, talking about it allows the opportunity to intervene and prevent a completed suicide.”


Suicide Assessment Five-step Evaluation and Triage (SAFE-T)

Suicide Assessment Five-step Evaluation and Triage (SAFE-T)


a. Suicidal behavior: history of prior suicide attempts, aborted suicide attempts, or self-injurious behavior

b. Current/past psychiatric disorders: especially mood disorders, psychotic disorders, alcohol/substance abuse, ADHD, TBI, PTSD, Cluster B personality disorders, conduct disorders (antisocial behavior, aggression, impulsivity) Co-morbidity and recent onset of illness increase risk

c. Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, global insomnia, and command hallucinations

d. Family history: of suicide, attempts, or psychiatric disorders requiring hospitalization

e. Precipitants/stressors/Interpersonal: triggering events leading to humiliation, shame, or despair (e.g, loss of relationship, financial or health status—real or anticipated). Ongoing medical illness (esp. CNS disorders, pain). Intoxication. Family turmoil/chaos. History of physical or sexual abuse. Social isolation

f. Change in treatment: discharge from psychiatric hospital, provider or treatment change

g. Access to firearms

2.   Protective factors, even if present, may not counteract significant acute risk

a. Internal: ability to cope with stress, religious beliefs, and frustration tolerance

b. External: responsibility to children or beloved pets, positive therapeutic relationships, and social supports

3.    Specific questioning about thoughts, plans, behaviors, and intent

a. Ideation: frequency, intensity, duration—in last 48 hours, past month, and worst ever

b. Plan: timing, location, lethality, availability, and preparatory acts

c. Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun) versus non-suicidal self injurious actions

d. Intent: extent to which the patient (1) expects to carry out the plan and (2) believes the plan/act to be lethal versus self-injurious.

e. Explore ambivalence: reasons to die versus reasons to live

›For Youths: ask parent/guardian about evidence of suicidal thoughts, plans, or behaviors, and changes in mood, behaviors, or disposition

›Homicide Inquiry: when indicated, esp. in character disordered or paranoid males dealing with loss or humiliation. Inquire in four areas listed above


a. Assessment of risk level is based on clinical judgment, after completing steps 1–3

b. Reassess as patient or environmental circumstances change

5.   Risk level and rationale; treatment plan to address/reduce current risk (e.g., medication, setting, psychotherapy, E.C.T., contact with significant others, consultation); firearms instructions, if relevant; follow-up plan. For youths, treatment plans should include roles for parent/guardian.

Entering the room with you, Dr. Lee greets Mrs. Gomez and her daughter, and thanks them for allowing you to interview them.

She tells Mrs. Gomez, “I understand that you’ve been having trouble sleeping – not unusual given your recent stresses. These can also lead to feelings of depression. I’d like to look into this by going over a short questionnaire with you.”

Dr. Lee goes over the questions on the   (GDS-SF) with Mrs. Gomez.  . This confirms depression, as a score of > 5 is consistent with the diagnosis of depression.

Dr. Lee then performs a   to screen for dementia, explaining to Mrs. Gomez that in cases like this, checking out the patient’s memory and concentration can help to rule out other disorders and can assist in planning treatment. She scores in the normal range.


Screening for Depression

The U.S. Preventive Services Task Force (USPSTF)  , but especially patients with chronic diseases like diabetes, as they are at high risk for depression.

The PHQ-2 is a simple screen that is 97% sensitive and 59% specific as a depression screen:

“Over the past two weeks, have you often been bothered by either of the following problems?”

1. Little interest or pleasure in doing things.

2. Feeling down, depressed, or hopeless.

If positive, it should be followed up by a diagnostic instrument such as:


·  (.pdf)


Screening for Dementia in Geriatric Patients with Depression

While screening for dementia in asymptomatic individuals is not recommended (I statement), screening is important in geriatric patients with depression because the Geriatric Depression Scale is less sensitive in patients experiencing dementia.

Two dementia screening tools are:


· The Mini-Mental State Exam (MMSE)

The Mini-Cog exam is faster and more sensitive and specific than the MMSE.










Patient Health Questionnaire, Two-Item Version (PHQ-2)

The U.S. Preventive Services Task Force (USPSTF) recommends   when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. Many family physicians and students are familiar with the nine-item depression survey from the Patient Health Questionnaire (PHQ-9), which has been demonstrated to be useful in diagnosis and tracking the severity of symptoms among patients with major depression. The length of the questionnaire has been a barrier to its use as a screening tool in primary care, where physicians are under considerable time pressure and face competing demands.

More recently, a shortened two-item version (PHQ-2) has been developed and validated in primary care. The PHQ-2 asks patients, “Over the last two weeks, how often have you been bothered by any of the following problems?” The two symptoms are “little interest or pleasure in doing things” and “feeling down, depressed, or hopeless.” For each question the patient can answer:

· Not at all (0 points)

· Several days (1 point)

· More than half the days (2 points)

· Nearly every day (3 points)

The score from the two symptom questions are then added together into a final score.

“Now that we know Mrs. Gomez is depressed,” states Dr. Lee, “Let’s talk about the different groups of antidepressant medications and how they work.”


Antidepressant Medications

Most antidepressants work by improving the levels of the neurotransmitters norepinephrine (NE), serotonin (5HT), and dopamine (DA). There are four major classes of antidepressants:





Selective serotonin reuptake inhibitors (SSRIs)

Selectively block reuptake of serotonin, potentiating serotonin’s effect on the postsynaptic neuron

Citalopram (Celexa)

Fluoxetine (Prozac)

Fluvoxamine (Luvox)

Paroxetine (Paxil)

Sertraline (Zoloft)

Escitalopram (Lexapro)

Tricyclic antidepressants (TCAs)

Block reuptake of norepinephrine and serotonin, potentiating their effects on the postsynaptic neuron

Nortriptyline (Pamelor)


Clomipramine (Anafranil)

Doxepin (Sinequan)

Monoamine oxidase (MAO) inhibitors

Block presynaptic catabolism of norepinephrine and serotonin (rarely used today)

Phenelzine (Nardil)

Tranylcypromine (Parnate)

Serotonin and norepinephrine reuptake inhibitors

Block reuptake of norepinephrine and serotonin, increasing their concentration/availability

Venlafaxine (Effexor) and Duloxetine (Cymbalta)


Norepinephrine and dopamine reuptake inhibitors

Bupropion (Wellbutrin)

Serotonin antagonist and reuptake inhibitors

Nefazodone (Serzone) and Trazodone (Desyrel)

Norepinephrine and serotonin antagonist, antihistaminic effects

Mirtazapine (Remeron)

Serotonin partial agonist and reuptake inhibitor

Vilazodone (Viibryd)

Which of the following would be considered treatment(s) of choice in this clinical scenario?

Cognitive-behavioral therapy


Sertraline – a selective serotonergic reuptake inhibitor (SSRI)

Dr. Lee concludes, “In the elderly, the chance of spontaneous remission of depression is much lower than in younger patients, so it’s best we start some form of therapy. I agree that an SSRI and/or psychotherapy would be a good choice for Mrs. Gomez. Also, the death of her husband and moving into a new environment proved to be stressful for her. Cognitive therapy can help her cope with these life changes.”


Management of Depression

When treating patients with major depression disorder, a biopsychosocial approach should be considered. “Bio” refers to pharmacotherapy; “psycho” refers to psychotherapy; and “social” refers to the identification of life stressors.

While either medication or counseling can be effective when used alone, using the two treatment modalities concurrently offers the patient the most beneficial and comprehensive therapy, and is associated with the highest rates of remission.


In a first episode of depression, it’s usually recommended that the patient take the medication for nine to 12 months, as stopping any sooner runs a high risk for recurrence. Recurrent episodes of depression are treated for two to three years. With multiple recurrences and – in the elderly, who experience increased rates of recurrence – continuous therapy should be considered.

SSRIs, such as sertraline, and SNRIs are generally considered safe and effective drugs for depression. They have lower rates of side effects compared to the older tricyclics and, unlike the tricyclics, have little risk of overdose. A tricyclic such as amitriptyline would not be a first-line approach because of its multiple side effects including anti-cholinergic effects and sedation.


Psychotherapy, most notably cognitive behavior therapy and interpersonal therapy, have been found as effective as psychotropic medications. It can be especially useful for patients who want to avoid medication.


Trials of mixed exercise indicated a small but statistically significant positive effect favoring exercise for the treatment of mild to moderate depression and, similarly to combining psychotherapy and medication, may have an additive effect when used in combination with other modalities.

Avoidance of other substances:

Additionally, avoidance of recreational drugs and excessive alcohol use is a necessary part of any treatment regimen.


While ECT is not an appropriate treatment for an initial episode of major depression, it is a safe and effective therapy that can be useful in patients with psychotic depression or severe nonpsychotic depression unresponsive to medications or psychotherapy and seems to improve mild cognitive impairment in depressed elderly.

What are the differences between the various SSRIs, and how do I choose which to use?” you ask Dr. Lee.

Antidepressant Profiles


The selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are all equally effective in geriatric patients but recent analysis shows SNRIs have a higher rate of adverse reactions. While matching the patient’s symptoms with the drug’s profile, keep in mind that each patient’s reaction to a medication is different and the final selection needs to be individualized.


Cost is another strong consideration. There are now generic preparations of many antidepressants, making them more affordable.

Drug-drug interactions:

Also, antidepressants have a wide variety of drug-drug interactions, most prominently through the P450 system.

Side effects

While antidepressants are relatively safe, there are potential side effects that vary in frequency and intensity between medications and the individual patient.




Fluoxetine (Prozac)

· Unusually long half life (two to four days), so effects can last for weeks after discontinuation.

· Most problematic (but uncommon) side effects include agitation, motor restlessness, decreased libido in women, and insomnia.

Sertraline (Zoloft)

· In addition to being a frequently used SSRI in pregnancy and breastfeeding, approved specifically for obsessive-compulsive, panic, and posttraumatic stress disorders.

· More gastrointestinal side effects than the other SSRIs.

Paroxetine (Paxil)

· Side effects can include significant weight gain, impotence, sedation, and constipation.

· Due to its short half-life, paroxetine is most likely of all the SSRIs to cause antidepressant discontinuation syndrome. 

· Paxil is Pregnancy Category D

Fluvoxamine (Luvox)

· Particularly useful in obsessive-compulsive disorder.

· Greater frequency of emesis compared to other SSRIs.

Citalopram (Celexa)

· Most common side effects include nausea, dry mouth, and somnolence.

· Maximum recommended dose: 20 mg per day for patients 60 years of age due to concerns of QT interval prolongation.

Escitalopram (Lexapro)

· Approved specifically for Generalized Anxiety Disorder.

· Overall, fewer side effects than citalopram.

“I’m glad Mrs. Gomez mentioned trying out a traditional herbal treatment,” Dr. Lee tells you, “This is the sort of thing you don’t want to miss. Do you know anything about zapote?”

You quickly search a drug program on your smartphone and an online database and identify a couple of websites that discuss zapote and its suggested uses, but not much else.


Complementary and Alternative Therapies

When obtaining a medication history, health care providers should ask routinely about herbal and other supplements – as well as over-the-counter medications and nutritional supplements. Patients frequently will not mention the use of complementary and alternative medical treatment unless they are asked about them. Be respectful when patients discuss alternative therapies, even if you are unfamiliar or skeptical about a particular treatment.

Herbs and similar supplements are a concern because of their potential to interact with conventional medications or produce side effects, just like conventional drugs. Even where they were obtained is important, as supplements have repeatedly been found to be contaminated with other herbs, heavy metals, and even prescription drugs. Only a few herbs have been scientifically studied, so information on their effectiveness is limited. St. John’s Wort has been shown possibly to be effective for short-term treatment of mild to moderate depression but data from trials is mixed.

Which tests would you order to rule out other causes for symptoms of insomnia, fatigue, and a depressed mood?

· A complete metabolic panel screens for electrolyte, renal, and hepatic problems

· A TSH can detect hypothyroidism

· A CBC will show anemia and vitamin deficiencies

· A urinalysis (F) is unlikely to be useful unless the depression or fatigue is of recent onset and there is suspicion of infection.

· A brain CT scan (A) is unlikely to yield results in the absence of obvious neurologic changes.

· A chest x-ray (C) is unlikely to add anything in the absence of specific symptoms such as cough or shortness of breath.

When you re-enter the exam room, Dr. Lee sits down to talk with Mrs. Gomez, “I would like to do a few tests to rule out any medical problem that might be causing your symptoms. But it looks as though you may be suffering from depression, which is completely understandable given the recent changes in your life.”This may …

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