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
,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.”
, 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.
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
,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.”
, 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.
