I HUMAN CASE STUDY 65-YEAR-OLD
WOMAN REASON FOR ENCOUNTER:
TROUBLE SLEEPING LOCATION:
OUTPATIENT CLINIC WITH X-RAY, ECG, AND
LABORATORY CAPABILITIES
,I HUMAN CASE STUDY 65-YEAR-OLD
WOMAN REASON FOR ENCOUNTER:
TROUBLE SLEEPING LOCATION:
OUTPATIENT CLINIC WITH X-RAY, ECG, AND
LABORATORY CAPABILITIES
,I HUMAN CASE STUDY 65-YEAR-OLD
WOMAN REASON FOR ENCOUNTER:
TROUBLE SLEEPING LOCATION:
OUTPATIENT CLINIC WITH X-RAY, ECG, AND
LABORATORY CAPABILITIES
Patient
Name: Regina Ricardo
Age: 65
Sex: Female
Date of Visit: [16-02-2026]
Chief Complaint: "I haven't been able to sleep well for the past few
months."
SUBJECTIVE
History of Presenting Illness:
Ms. Ricardo presents to the clinic with a 4-month history of progressively
worsening sleep disturbance. She reports significant difficulty with sleep
initiation, often lying awake for 1-2 hours before falling asleep. Her
primary complaint is sleep maintenance insomnia, as she wakes up 3-4
times per night and struggles to return to sleep. She estimates her total
nightly sleep at 4-5 hours.
She describes her mind as "racing" with worries about her family and daily
tasks when she tries to sleep. She denies any uncomfortable sensations
, I HUMAN CASE STUDY 65-YEAR-OLD
WOMAN REASON FOR ENCOUNTER:
TROUBLE SLEEPING LOCATION:
OUTPATIENT CLINIC WITH X-RAY, ECG, AND
LABORATORY CAPABILITIES
in her legs at rest, though she does report occasional leg jerks, which her
husband has noticed. Her husband also reports that her snoring is loud
and has recently been punctuated by brief pauses in breathing. She wakes
up with a dry mouth and a headache most mornings.
Consequences of her poor sleep include debilitating daytime fatigue,
irritability, and difficulty concentrating on tasks like reading. She has
stopped her daily afternoon walk because she feels too tired. She denies
any episodes of falling asleep while driving. She has tried
over-the-counter diphenhydramine (Benadryl) on some nights, which
helps her fall asleep but leaves her feeling "groggy" the next day. She has
not tried melatonin or any prescription sleep aids.
Past Medical History:
● Hypertension (diagnosed 10 years ago)
● Type 2 Diabetes Mellitus (diagnosed 5 years ago)
● Osteoarthritis of both knees
● Depression (diagnosed 20 years ago, currently stable)
Past Surgical History:
● Cholecystectomy (1995)
WOMAN REASON FOR ENCOUNTER:
TROUBLE SLEEPING LOCATION:
OUTPATIENT CLINIC WITH X-RAY, ECG, AND
LABORATORY CAPABILITIES
,I HUMAN CASE STUDY 65-YEAR-OLD
WOMAN REASON FOR ENCOUNTER:
TROUBLE SLEEPING LOCATION:
OUTPATIENT CLINIC WITH X-RAY, ECG, AND
LABORATORY CAPABILITIES
,I HUMAN CASE STUDY 65-YEAR-OLD
WOMAN REASON FOR ENCOUNTER:
TROUBLE SLEEPING LOCATION:
OUTPATIENT CLINIC WITH X-RAY, ECG, AND
LABORATORY CAPABILITIES
Patient
Name: Regina Ricardo
Age: 65
Sex: Female
Date of Visit: [16-02-2026]
Chief Complaint: "I haven't been able to sleep well for the past few
months."
SUBJECTIVE
History of Presenting Illness:
Ms. Ricardo presents to the clinic with a 4-month history of progressively
worsening sleep disturbance. She reports significant difficulty with sleep
initiation, often lying awake for 1-2 hours before falling asleep. Her
primary complaint is sleep maintenance insomnia, as she wakes up 3-4
times per night and struggles to return to sleep. She estimates her total
nightly sleep at 4-5 hours.
She describes her mind as "racing" with worries about her family and daily
tasks when she tries to sleep. She denies any uncomfortable sensations
, I HUMAN CASE STUDY 65-YEAR-OLD
WOMAN REASON FOR ENCOUNTER:
TROUBLE SLEEPING LOCATION:
OUTPATIENT CLINIC WITH X-RAY, ECG, AND
LABORATORY CAPABILITIES
in her legs at rest, though she does report occasional leg jerks, which her
husband has noticed. Her husband also reports that her snoring is loud
and has recently been punctuated by brief pauses in breathing. She wakes
up with a dry mouth and a headache most mornings.
Consequences of her poor sleep include debilitating daytime fatigue,
irritability, and difficulty concentrating on tasks like reading. She has
stopped her daily afternoon walk because she feels too tired. She denies
any episodes of falling asleep while driving. She has tried
over-the-counter diphenhydramine (Benadryl) on some nights, which
helps her fall asleep but leaves her feeling "groggy" the next day. She has
not tried melatonin or any prescription sleep aids.
Past Medical History:
● Hypertension (diagnosed 10 years ago)
● Type 2 Diabetes Mellitus (diagnosed 5 years ago)
● Osteoarthritis of both knees
● Depression (diagnosed 20 years ago, currently stable)
Past Surgical History:
● Cholecystectomy (1995)
