, Human Case Week #9
65-Year-Old Female – Trouble Sleeping
1. 🧠 Clinical Judgment Overview
This case commonly points toward Insomnia
Disorder, but your goal is to rule out underlying
causes (medical, psychiatric, medication-related).
2. 📋 Step-by-Step Patient Assessment
A. Chief Complaint (CC)
• “I can’t sleep” / “Trouble falling or staying
asleep”
B. History of Present Illness (HPI) – OLDCARTS
• Onset: When did the sleep problem begin?
• Location: (Not applicable, but assess body
discomfort)
• Duration: Nights per week? Hours of sleep?
• Character: Difficulty falling asleep vs
frequent awakenings
• Aggravating factors: Stress? Caffeine? Pain?
• Relieving factors: Medications? Herbal
remedies?
• Timing: Worse at night? Early awakening?
• Severity: Daytime fatigue? Functional
impairment?
65-Year-Old Female – Trouble Sleeping
1. 🧠 Clinical Judgment Overview
This case commonly points toward Insomnia
Disorder, but your goal is to rule out underlying
causes (medical, psychiatric, medication-related).
2. 📋 Step-by-Step Patient Assessment
A. Chief Complaint (CC)
• “I can’t sleep” / “Trouble falling or staying
asleep”
B. History of Present Illness (HPI) – OLDCARTS
• Onset: When did the sleep problem begin?
• Location: (Not applicable, but assess body
discomfort)
• Duration: Nights per week? Hours of sleep?
• Character: Difficulty falling asleep vs
frequent awakenings
• Aggravating factors: Stress? Caffeine? Pain?
• Relieving factors: Medications? Herbal
remedies?
• Timing: Worse at night? Early awakening?
• Severity: Daytime fatigue? Functional
impairment?
