REASON FOR ENCOUNTER: TROUBLE
SLEEPING (Class 6550)
,
, Patient: 66-Year-Old Female
Chief Complaint (CC):
“I can’t sleep well at night. It’s been
going on for a few months.”
HPI – History of Present Illness
History obtained from: Patient
(reliable historian)
Presenting Problem: Insomnia
HPI (Expanded):
The patient is a 66-year-old female
who presents with complaints of
difficulty falling and staying asleep for
the past 4 months. She describes
waking up 2–3 times per night, with
difficulty returning to sleep, and
sometimes lies awake until dawn. She