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I-Human Case Week #9: 65-Year-Old Female Patient Presenting with Trouble Sleeping (Class 6531)

HEAL100 Health Care — exam and revision material · Other

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Health Care exam material, 38 pages. Originally published on StudyMerit.

Pages
38
Academic year
2025/2026
Language
English

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I - HUMAN Case Study Week 9: Comprehensive for a 65 - Year - Old Female with Chronic Insomnia (Trouble Sleeping) – CLASS 6531 Advanced Practice Nursing This in - depth I - HUMAN case study for Week 9 of CLASS 6531 presents a comprehensive for a 65 - year - old female experiencing chronic insomnia. The case includes a detailed history of present illness, full review of systems, physical exam findings, differential diagnoses, evidence - based assessment, and a patient - centered management plan empha sizing CBT - I and safe pharmacologic therapy for older adults. • I - HUMAN case study • Chronic insomnia case study • Insomnia note • CLASS 6531 Week 9

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2 | P a g e Course: CLASS 6531 Patient: 65 - year - old Female Diagnosis: Chronic Insomnia Identifying Data • Name: Mrs. J.D. (initials only) • Age: 65 years • Gender: Female

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• Ethnicity: Caucasian • Marital Status: Widowed • Occupation: Retired elementary school teacher • Source of History: Patient (reliable) • Date of Encounter: Week 9 Chief Complaint (CC) “I can’t sleep at night. I’m lucky if I get 3 to 4 hours of sleep.” History of Present Illness (HPI) Mrs. J.D. is a 65 - year - old female who presents with complaints of difficulty sleeping for the past 6 months . She reports trouble falling asleep and staying asleep , waking multiple times throughout the night, and early morning awakening around 3 – 4 a.m. She states her sleep difficulty occurs at least 5 nights per week and has progressively worsened. She describes lying awake for over an hour before falling asleep and waking up 3 – 4 times per night without being able to return to sleep. She reports feeling fatigued, irritable, and unable to concentrate during the day. She denies snoring, witnessed apnea, nocturnal choking, or gasping for air. She reports increased stress since the death of her husband one year ago and admits to occasional daytime napping. She drinks 2 cups of coffee daily , with one cup consumed in the late afternoon. She has tried over - the - counter melatonin with minimal relief. She denies chest pain, shortness of breath, nocturia, pain, restless legs, depression, or anxiety symptoms. No recent medication changes. Past Medical History (PMH) • Hypertension – diagnosed 10 years ago • Hyperlipidemia – diagnosed 8 years ago • Osteoarthritis (knees) Past Surgical History (PSH)

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