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iHuman Case Study: 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, 17 pages. Originally published on StudyMerit.

Pages
17
Academic year
2025/2026
Language
English

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WEEK 9 IHUMAN CASE STUDY FOR A 65 YEARS OLD FEMALE PATIENT PRESENTING WITH TROUBLE SLEEPING – CHRONIC INSOMNIA (CLASS 6531) WEEK #9 - LOCATION ; OUTPATIENT CLINIC WITH X-RAY,ECG,AND LABORATORY CAPABILITIES LATEST UPDATE WITH SOAP NOTE, INCLUDES HPI, PE, DIFFERENTIAL DIAGNOSIS, AND MANAGEMENT PLAN Course: NRNP 6531 – Advanced Practice Care of Adults Across the Lifespan Institution: Walden University Week: 9 Case Focus: Sleep Disorders in Older Adults Clinical Setting: Outpatient Primary Care / Family Practice Educational Purpose: Diagnostic reasoning, differential development, evidence- based management, and guideline-supported treatment planning for chronic insomnia in an older adult

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Patient Information Age: 65 years Sex: Female Race/Ethnicity: Caucasian Marital Status: Married Occupation: Retired school administrator Insurance: Medicare Source of History: Patient (reliable historian) Chief Health Concern Category: Sleep disturbance / insomnia Functional Status: Independent in activities of daily living (ADLs); reports reduced daytime energy Health Literacy: Adequate Advance Directives: None reported Chief Complaint (CC) “I have trouble falling asleep and staying asleep almost every night.”

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History of Present Illness (HPI) The patient is a 65-year-old female presenting for evaluation of chronic sleep disturbance characterized by difficulty initiating and maintaining sleep for approximately 5 – 6 years , with notable worsening over the past 6 months . She reports a sleep latency of 60 – 90 minutes , frequent nocturnal awakenings ( 3 – 4 times per night ), and difficulty returning to sleep once awakened. Average total sleep time is estimated at 3 – 4 hours per night , significantly below her desired amount. The insomnia occurs most nights of the week (≥5 nights/week) and results in daytime fatigue, decreased concentration, irritability, and reduced overall functioning . She denies unintentional daytime sleep episodes but reports feeling persistently unrefreshed. She notes increased anxiety surrounding bedtime, often worrying about not sleeping and its impact on her health. Symptoms are exacerbated by psychosocial stressors , including adjustment to retirement and caregiving responsibilities for her chronically ill spouse. She reports cognitive hyperarousal , describing racing thoughts at night. She denies symptoms suggestive of other primary sleep disorders, including loud snoring, witnessed apneas, nocturnal choking, restless legs, parasomnias, or circadian rhythm disturbance. She has attempted multiple over-the-counter sleep aids, including diphenhydramine and melatonin (5 – 10 mg nightly) , with minimal benefit and undesirable side effects such as morning grogginess. She denies prior prescription sleep medications. No recent medication changes, travel, or acute illnesses are reported.

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