1
1 1
,1
1 1
CHIEF COMPLAINT
1 1
“I1haven’t1been1sleeping1well1for1months1and1I’m1always1on1edge.”1
HISTORY OF PRESENT I ILLNESS
1 1 1 1 1
Marcus1Johnson1is1a142-year-
old1male1Army1veteran1who1presents1for1evaluation1of1chronic1sleep1disturbance,1persistent1irritability,1
and1difficulty1functioning1at1work1and1home.1He1reports1that1for1the1past181to1101months1he1has1been1sl
eeping1poorly,1averaging131to141hours1of1fragmented1sleep1per1night.1He1has1difficulty1falling1asleep1and1
wakes1multiple1times1throughout1the1night1due1to1racing1thoughts1and1frequent1nightmares.1
He1describes1his1mood1as1“constantly1tense1and1angry”1and1admits1to1frequent1outbursts1toward1cowor
kers1and1family1members.1He1reports1feeling1hyperalert,1easily1startled1by1loud1noises,1and1unable1to1re
lax1even1in1safe1environments.1He1endorses1intrusive1thoughts1related1to1military1service1but1avoids1dis
cussing1details.1
He1reports1decreased1concentration,1forgetfulness,1chronic1fatigue,1headaches,1and1muscle1tension.1
He1denies1suicidal1ideation1but1admits1to1passive1thoughts1of1“not1wanting1to1wake1up1sometimes.”1N
o1recent1illness,1head1trauma,1or1substance1intoxication.1
PAST MEDICAL HISTORY
1 1 1
• Post-traumatic1stress1disorder1(diagnosed161years1ago,1poor1follow-up)1
• Hypertension1
• Chronic1low1back1pain1
1 1
,1
1 1
CHIEF COMPLAINT
1 1
“I1haven’t1been1sleeping1well1for1months1and1I’m1always1on1edge.”1
HISTORY OF PRESENT I ILLNESS
1 1 1 1 1
Marcus1Johnson1is1a142-year-
old1male1Army1veteran1who1presents1for1evaluation1of1chronic1sleep1disturbance,1persistent1irritability,1
and1difficulty1functioning1at1work1and1home.1He1reports1that1for1the1past181to1101months1he1has1been1sl
eeping1poorly,1averaging131to141hours1of1fragmented1sleep1per1night.1He1has1difficulty1falling1asleep1and1
wakes1multiple1times1throughout1the1night1due1to1racing1thoughts1and1frequent1nightmares.1
He1describes1his1mood1as1“constantly1tense1and1angry”1and1admits1to1frequent1outbursts1toward1cowor
kers1and1family1members.1He1reports1feeling1hyperalert,1easily1startled1by1loud1noises,1and1unable1to1re
lax1even1in1safe1environments.1He1endorses1intrusive1thoughts1related1to1military1service1but1avoids1dis
cussing1details.1
He1reports1decreased1concentration,1forgetfulness,1chronic1fatigue,1headaches,1and1muscle1tension.1
He1denies1suicidal1ideation1but1admits1to1passive1thoughts1of1“not1wanting1to1wake1up1sometimes.”1N
o1recent1illness,1head1trauma,1or1substance1intoxication.1
PAST MEDICAL HISTORY
1 1 1
• Post-traumatic1stress1disorder1(diagnosed161years1ago,1poor1follow-up)1
• Hypertension1
• Chronic1low1back1pain1
