iHuman Case Study: 65-Year-Old Female
Patient Presenting with Trouble Sleeping
(Class 6531)
,Human Case Study: SOAP Note
Student Name: [Your Name]
Course: Class 6531: Advanced Health Assessment
Patient Initials: R.R.
Age: 65
Gender: Female
Chief Complaint: "I haven't been sleeping well for the past few months."
, SUBJECTIVE
History of Present Illness (HPI):
Regina Ricardo is a 65-year-old widowed Caucasian female who presents
to the clinic with a 4-month history of progressive insomnia. She reports
difficulty with both sleep initiation (taking 1-2 hours to fall asleep) and
sleep maintenance (waking 2-3 times per night with difficulty returning to
sleep). She experiences early morning awakening around 3:00 AM and is
unable to fall back asleep. Total sleep time averages 4-5 hours per night.
She describes her mind as "racing" when she lies down, often worrying
about her health, finances, and living alone. She reports waking up
unrefreshed with significant daytime fatigue, irritability, and difficulty
concentrating (e.g., cannot focus on reading or follow television plots).
She has tried over-the-counter diphenhydramine (Benadryl) 25 mg 3-4
times per week, which initially helped but has become ineffective. She
drinks 1 glass of wine most nights to help her relax before bed.
She endorses anhedonia (loss of interest in gardening and knitting), low
mood, and increased anxiety about her sleep. She denies suicidal ideation,
hopelessness, or plan. She lives alone and reports feeling "isolated" since
her husband passed 5 years ago.
Pertinent Positives:
● Initial, middle, and terminal insomnia
● Daytime fatigue and impaired concentration
● Low mood and anhedonia
● Occasional nocturia (1x/night)
● Chronic knee pain (osteoarthritis)
Pertinent Negatives:
Patient Presenting with Trouble Sleeping
(Class 6531)
,Human Case Study: SOAP Note
Student Name: [Your Name]
Course: Class 6531: Advanced Health Assessment
Patient Initials: R.R.
Age: 65
Gender: Female
Chief Complaint: "I haven't been sleeping well for the past few months."
, SUBJECTIVE
History of Present Illness (HPI):
Regina Ricardo is a 65-year-old widowed Caucasian female who presents
to the clinic with a 4-month history of progressive insomnia. She reports
difficulty with both sleep initiation (taking 1-2 hours to fall asleep) and
sleep maintenance (waking 2-3 times per night with difficulty returning to
sleep). She experiences early morning awakening around 3:00 AM and is
unable to fall back asleep. Total sleep time averages 4-5 hours per night.
She describes her mind as "racing" when she lies down, often worrying
about her health, finances, and living alone. She reports waking up
unrefreshed with significant daytime fatigue, irritability, and difficulty
concentrating (e.g., cannot focus on reading or follow television plots).
She has tried over-the-counter diphenhydramine (Benadryl) 25 mg 3-4
times per week, which initially helped but has become ineffective. She
drinks 1 glass of wine most nights to help her relax before bed.
She endorses anhedonia (loss of interest in gardening and knitting), low
mood, and increased anxiety about her sleep. She denies suicidal ideation,
hopelessness, or plan. She lives alone and reports feeling "isolated" since
her husband passed 5 years ago.
Pertinent Positives:
● Initial, middle, and terminal insomnia
● Daytime fatigue and impaired concentration
● Low mood and anhedonia
● Occasional nocturia (1x/night)
● Chronic knee pain (osteoarthritis)
Pertinent Negatives:
