I-Human Case Week #9: 65-Year-
Old Female PatIent PresentIng
WItH trOuble sleePIng (Class
6531)
IDENTIFYING DATA
Attribute Detail
Name Margaret Johnson (initials: M.J. per i-Human documentation)
Age 65 years
Gender Female
Height 5’2” (157.5 cm)
Weight 145 lb (65.8 kg)
BMI 26.5 kg/m² (overweight)
Ethnicity Caucasian
Setting Outpatient primary care clinic
,Attribute Detail
Encounter Date January 2026
Provider Role Nurse Practitioner Student (precepted)
CHIEF COMPLAINT (CC)
"I have not been able to sleep well for months, and it’s getting worse. I feel so
tired during the day that I can’t do my normal activities."
HISTORY OF PRESENT ILLNESS (HPI) – OLD-CARTS FORMAT
Onset
• Gradual onset approximately 5–6 years ago, with progressive worsening
over the past 6 months
• Patient states: "It started about 6 months ago, maybe when my arthritis got
worse"
Location
• "No pain in my chest or back, but my knees hurt at night"
• Pain localized to bilateral knees (consistent with known osteoarthritis)
Duration
• Sleep-onset insomnia: Takes 1–2 hours to fall asleep most nights (sleep
latency 60–90 minutes)
• Sleep-maintenance insomnia: Wakes 3–4 times per night, with difficulty
returning to sleep
, • Total sleep time: Approximately 4–5 hours per night (down from usual 7–8
hours)
• Symptoms occur 4–5 nights per week
Character
• "It’s like my mind won’t shut off. I think about my health, my family, and
what I need to do the next day" — indicates anxiety-related rumination
• Describes fragmented, unrefreshing sleep
• Denies snoring, gasping, or witnessed apneas (per patient report; no
partner to observe)
Aggravating Factors
Factor Clinical Relevance
Nighttime knee pain Osteoarthritis pain disrupts sleep continuit
Stress/worry (health, family, appointments) Exacerbates initial insomnia
Evening tea/caffeine (last cup at 3–4 PM) Caffeine contributes to sleep onset delay
Irregular bedtime and wake time Disrupts circadian rhythm
Evening screen time (TV, smartphone in bed) Blue light suppresses melatonin
Alleviating Factors
Factor Clinical Relevance
Warm bath before bed Non-pharmacologic relaxation
, Factor Clinical Relevance
Reading a book (dim light) Promotes sleep onset
Acetaminophen at bedtime Addresses pain component
Lying down (for back/knee pain) Reduces discomfort
Timing
• Worse on nights with anticipated stress (appointments, caregiving
responsibilities)
• Symptoms more pronounced since retirement (6 months ago) due to
reduced daytime structure
Severity
• 8/10 on sleep disturbance scale
• Significant daytime impairment: Fatigue, irritability, difficulty
concentrating, inability to perform morning walks, decreased enjoyment of
hobbies (gardening, reading)
ASSOCIATED SYMPTOMS
Symptom Present? Details
Daytime fatigue Yes Severe, affecting ADLs
Low mood Yes Since husband’s death 6 months ago
Old Female PatIent PresentIng
WItH trOuble sleePIng (Class
6531)
IDENTIFYING DATA
Attribute Detail
Name Margaret Johnson (initials: M.J. per i-Human documentation)
Age 65 years
Gender Female
Height 5’2” (157.5 cm)
Weight 145 lb (65.8 kg)
BMI 26.5 kg/m² (overweight)
Ethnicity Caucasian
Setting Outpatient primary care clinic
,Attribute Detail
Encounter Date January 2026
Provider Role Nurse Practitioner Student (precepted)
CHIEF COMPLAINT (CC)
"I have not been able to sleep well for months, and it’s getting worse. I feel so
tired during the day that I can’t do my normal activities."
HISTORY OF PRESENT ILLNESS (HPI) – OLD-CARTS FORMAT
Onset
• Gradual onset approximately 5–6 years ago, with progressive worsening
over the past 6 months
• Patient states: "It started about 6 months ago, maybe when my arthritis got
worse"
Location
• "No pain in my chest or back, but my knees hurt at night"
• Pain localized to bilateral knees (consistent with known osteoarthritis)
Duration
• Sleep-onset insomnia: Takes 1–2 hours to fall asleep most nights (sleep
latency 60–90 minutes)
• Sleep-maintenance insomnia: Wakes 3–4 times per night, with difficulty
returning to sleep
, • Total sleep time: Approximately 4–5 hours per night (down from usual 7–8
hours)
• Symptoms occur 4–5 nights per week
Character
• "It’s like my mind won’t shut off. I think about my health, my family, and
what I need to do the next day" — indicates anxiety-related rumination
• Describes fragmented, unrefreshing sleep
• Denies snoring, gasping, or witnessed apneas (per patient report; no
partner to observe)
Aggravating Factors
Factor Clinical Relevance
Nighttime knee pain Osteoarthritis pain disrupts sleep continuit
Stress/worry (health, family, appointments) Exacerbates initial insomnia
Evening tea/caffeine (last cup at 3–4 PM) Caffeine contributes to sleep onset delay
Irregular bedtime and wake time Disrupts circadian rhythm
Evening screen time (TV, smartphone in bed) Blue light suppresses melatonin
Alleviating Factors
Factor Clinical Relevance
Warm bath before bed Non-pharmacologic relaxation
, Factor Clinical Relevance
Reading a book (dim light) Promotes sleep onset
Acetaminophen at bedtime Addresses pain component
Lying down (for back/knee pain) Reduces discomfort
Timing
• Worse on nights with anticipated stress (appointments, caregiving
responsibilities)
• Symptoms more pronounced since retirement (6 months ago) due to
reduced daytime structure
Severity
• 8/10 on sleep disturbance scale
• Significant daytime impairment: Fatigue, irritability, difficulty
concentrating, inability to perform morning walks, decreased enjoyment of
hobbies (gardening, reading)
ASSOCIATED SYMPTOMS
Symptom Present? Details
Daytime fatigue Yes Severe, affecting ADLs
Low mood Yes Since husband’s death 6 months ago
