Comprehensive I Human Case Study: 65-Year-Old Female
Patient Presenting with Trouble Sleeping (Class 6531) - Week #9
| Includes HPI, PE, Differential Diagnosis, and Management Plan |
,
,
, Patient Information
• Name: Ms. Jane Thompson
• Age: 65
• Sex: Female
• Date: [Insert Date]
• Chief Complaint: "I can't sleep at night. It’s been going on for weeks."
History of Present Illness (HPI)
Ms. Jane Thompson is a 65-year-old postmenopausal woman presenting with
complaints of trouble sleeping for the past 6 weeks. She reports difficulty falling
asleep and frequent nighttime awakenings, sometimes lying awake for 1–2 hours.
Sleep latency is increased, and she sleeps approximately 3–4 hours per night,
significantly less than her baseline of 7 hours. She denies loud snoring, witnessed
apneas, or gasping during sleep.
She admits to increased stress, related to the recent death of her sister and financial
concerns. She denies napping during the day, caffeine after 3 p.m., alcohol or drug use.
She does not use any over-the- counter or prescription sleep aids.
Other symptoms:
• Daytime fatigue and irritability
• No chest pain, shortness of breath, or palpitations
• Mild anxiety, no suicidal ideation
• Occasional hot flashes and night sweats
Past Medical History
• Hypertension – well controlled on lisinopril
• Hyperlipidemia
• Osteoarthritis – knees
• No history of depression or psychiatric illness
Surgical History
• Hysterectomy (age 52, fibroids)
Medications
Patient Presenting with Trouble Sleeping (Class 6531) - Week #9
| Includes HPI, PE, Differential Diagnosis, and Management Plan |
,
,
, Patient Information
• Name: Ms. Jane Thompson
• Age: 65
• Sex: Female
• Date: [Insert Date]
• Chief Complaint: "I can't sleep at night. It’s been going on for weeks."
History of Present Illness (HPI)
Ms. Jane Thompson is a 65-year-old postmenopausal woman presenting with
complaints of trouble sleeping for the past 6 weeks. She reports difficulty falling
asleep and frequent nighttime awakenings, sometimes lying awake for 1–2 hours.
Sleep latency is increased, and she sleeps approximately 3–4 hours per night,
significantly less than her baseline of 7 hours. She denies loud snoring, witnessed
apneas, or gasping during sleep.
She admits to increased stress, related to the recent death of her sister and financial
concerns. She denies napping during the day, caffeine after 3 p.m., alcohol or drug use.
She does not use any over-the- counter or prescription sleep aids.
Other symptoms:
• Daytime fatigue and irritability
• No chest pain, shortness of breath, or palpitations
• Mild anxiety, no suicidal ideation
• Occasional hot flashes and night sweats
Past Medical History
• Hypertension – well controlled on lisinopril
• Hyperlipidemia
• Osteoarthritis – knees
• No history of depression or psychiatric illness
Surgical History
• Hysterectomy (age 52, fibroids)
Medications
