I-Human Case Week #9: 65-Year-Old
Female Patient Presenting with
Trouble Sleeping (Class 6531)
EXAM
Patient Bio Data
Name: Margaret Johnson
Age: 65 years old
Sex: Female
Date of Birth / Age context: Older adult, retired
Occupation: Retired elementary school teacher
Living Situation: Lives alone in a private home
Marital Status: Widowed (husband died 6 months ago)
, Social Support: Attends church; limited social contact since friend's death
BMI: 26.5 kg/m² (overweight)
Vital Signs at Presentation: BP 130-132/72-78, Pulse 102 bpm, Temp 99.2°F, RR
14, O2 sat 98%
Allergies: No known drug, food, or environmental allergies
Substance Use: No alcohol, no smoking; one cup of coffee in the morning only
Functional Status: Walks 3 times per week; does light gardening; reads; recently
stopped attending book club due to low mood
Past Medical History: Hypertension (10 years), osteoarthritis
Past Surgical History: Cholecystectomy at age 50
Current Medications: Hydrochlorothiazide 25 mg daily; acetaminophen PRN
Family History: Mother died at 83 (stroke), father died at 80 (type 2 diabetes); no
known family history of mental illness or sleep disorders
History of Present Illness (HPI):
Margaret Johnson is a 65-year-old female who presents to the primary care clinic with a
chief complaint of difficulty sleeping for the past 3 months that has been gradually
worsening. She reports taking 1-2 hours to fall asleep most nights and experiences
frequent awakenings with difficulty returning to sleep. She estimates sleeping 4-5 hours
per night, compared to her usual 7-8 hours prior to symptom onset. The patient reports
feeling fatigued during the day, with difficulty concentrating and increased irritability,
which are affecting her quality of life and social interactions. She denies excessive
daytime sleepiness or falling asleep unintentionally during the day. Associated
symptoms include low mood, decreased interest in hobbies (e.g., gardening, reading),
and occasional feelings of hopelessness, particularly since her husband's death 6
months ago. She denies suicidal ideation, hallucinations, hallucinations, or significant
weight changes, though she notes a slight decrease in appetite. She reports no snoring,
gasping, or witnessed apneas during sleep, and no leg twitching or discomfort at night.
She denies recent stressors other than ongoing grief, no new medications, and no
changes in caffeine or alcohol intake. She has tried over-the-counter melatonin (3 mg)
without significant improvement and avoids sleep aids due to concerns about
dependency.
Past Medical History (PMH):
Hypertension, diagnosed 10 years ago, controlled with hydrochlorothiazide 25 mg daily
Osteoarthritis, managed with acetaminophen as needed
Female Patient Presenting with
Trouble Sleeping (Class 6531)
EXAM
Patient Bio Data
Name: Margaret Johnson
Age: 65 years old
Sex: Female
Date of Birth / Age context: Older adult, retired
Occupation: Retired elementary school teacher
Living Situation: Lives alone in a private home
Marital Status: Widowed (husband died 6 months ago)
, Social Support: Attends church; limited social contact since friend's death
BMI: 26.5 kg/m² (overweight)
Vital Signs at Presentation: BP 130-132/72-78, Pulse 102 bpm, Temp 99.2°F, RR
14, O2 sat 98%
Allergies: No known drug, food, or environmental allergies
Substance Use: No alcohol, no smoking; one cup of coffee in the morning only
Functional Status: Walks 3 times per week; does light gardening; reads; recently
stopped attending book club due to low mood
Past Medical History: Hypertension (10 years), osteoarthritis
Past Surgical History: Cholecystectomy at age 50
Current Medications: Hydrochlorothiazide 25 mg daily; acetaminophen PRN
Family History: Mother died at 83 (stroke), father died at 80 (type 2 diabetes); no
known family history of mental illness or sleep disorders
History of Present Illness (HPI):
Margaret Johnson is a 65-year-old female who presents to the primary care clinic with a
chief complaint of difficulty sleeping for the past 3 months that has been gradually
worsening. She reports taking 1-2 hours to fall asleep most nights and experiences
frequent awakenings with difficulty returning to sleep. She estimates sleeping 4-5 hours
per night, compared to her usual 7-8 hours prior to symptom onset. The patient reports
feeling fatigued during the day, with difficulty concentrating and increased irritability,
which are affecting her quality of life and social interactions. She denies excessive
daytime sleepiness or falling asleep unintentionally during the day. Associated
symptoms include low mood, decreased interest in hobbies (e.g., gardening, reading),
and occasional feelings of hopelessness, particularly since her husband's death 6
months ago. She denies suicidal ideation, hallucinations, hallucinations, or significant
weight changes, though she notes a slight decrease in appetite. She reports no snoring,
gasping, or witnessed apneas during sleep, and no leg twitching or discomfort at night.
She denies recent stressors other than ongoing grief, no new medications, and no
changes in caffeine or alcohol intake. She has tried over-the-counter melatonin (3 mg)
without significant improvement and avoids sleep aids due to concerns about
dependency.
Past Medical History (PMH):
Hypertension, diagnosed 10 years ago, controlled with hydrochlorothiazide 25 mg daily
Osteoarthritis, managed with acetaminophen as needed
