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iHuman Case Study: 65-Year-Old Female Patient Presenting with Trouble Sleeping (Class 6531) - Week #9
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passed away. It’s gotten worse over time.”
nights a week, but now it’s almost every night.” Location
affected, like falling asleep or staying asleep?
up several times during the night.” Duration
awakenings?
can’t get back to sleep easily.” Characteristics
restless and frustrated.”
at all.”
sleep problems on your daily life?
I’m irritable all the time.” Aggravating Factors
husband’s death. Also, drinking tea in the evening or watching TV late at night.”
sleep?
lights or noise at night make it harder to sleep.” Relieving Factors
me groggy the next day. Reading a book or relaxing in a quiet room can help me calm down.”
much difference.” Timing
alone now.”
the energy I used to.” Past Medical History (PMH)
ago, and osteoarthritis in my knees.”
sleep apnea?
this.”
Parkinson’s?
condition, like depression or anxiety?
husband passed.”
injuries?
vaccine a couple of years ago.” Medications
or supplements?
acetaminophen 500 mg as needed for knee pain, and Benadryl 25 mg a couple of times a week for sleep.”
start it?
nights a week when I really can’t sleep.”
much.” Allergies
things?
Social History (SH)
affected your work?
tiredness makes it hard to stay active or do things I enjoy.”
Family History (FH)
insomnia or sleep apnea?
sleep issues.”
attack at 80. My father had diabetes and passed at 75.”
disorders?
things like Parkinson’s.” Review of Systems (ROS) General:
fevers or chills.”
Neurological:
to concentrate since I’m not sleeping well.”
Psychiatric:
harming yourself?
died, and I get tearful sometimes, but I don’t want to hurt myself.”
as much.” Cardiovascular:
Respiratory:
Gastrointestinal:
bowel changes.” Musculoskeletal:
weakness.” Endocrine:
frequent awakenings, and feeling unrefreshed, which impacts her daily energy and mood. History of Present Illness (HPI) Using the OLD CARTS mnemonic, a detailed history was obtained to characterize the insomnia and identify contributing factors: Onset: Insomnia began approximately six months ago, shortly after the death of her spouse, with gradual worsening. Location: Not applicable (sleep disturbance). Duration: Difficulty falling asleep (30–60 minutes), frequent awakenings (3– 4 times per night), and total sleep time of 4–5 hours per night. Characteristics: Reports lying awake worrying, unable to “shut off” thoughts. Feels unrefreshed upon waking, with daytime fatigue and irritability. Aggravating Factors: Stress, particularly related to grief and loneliness, worsens sleep. Evening caffeine (tea) and irregular bedtime exacerbate symptoms. Relieving Factors: Occasional use of over-the-counter (OTC) diphenhydramine ( mg) provides mild improvement but causes morning grogginess. Relaxation techniques (e.g., reading) sometimes help. Timing: Symptoms occur nightly, worse when stressed or after consuming caffeine late in the day. Severity: Significantly impacts quality of life, causing daytime fatigue, difficulty concentrating, and low mood. Patient rates severity as 7/10 due to functional impairment. Associated Symptoms: Psychological: Increased anxiety, low mood, and occasional tearfulness related to spouse’s death. Neurological: No headaches, tremors, or memory loss, but reports difficulty focusing.
General: Fatigue, no significant weight changes or fever. Gastrointestinal: Occasional heartburn, no nausea or vomiting. Past Medical History (PMH) Hypertension, diagnosed 10 years ago, controlled with lisinopril 10 mg daily. Osteoarthritis, managed with acetaminophen PRN. No history of sleep disorders, neurological conditions, or psychiatric diagnoses. No recent hospitalizations or surgeries. Immunizations up to date, including influenza and pneumococcal vaccines. Medications Lisinopril 10 mg daily for hypertension. Acetaminophen 500 mg PRN for osteoarthritis pain (1–2 times/week). Diphenhydramine 25 mg PRN for sleep (2–3 times/week, started 3 months ago). Allergies No known drug, food, or environmental allergies. Social History (SH) Occupation: Retired schoolteacher, living alone since spouse’s death 6 months ago. Lifestyle: Tobacco: Never smoker. Alcohol: Rare, 1 glass of wine/month. Illicit Drugs: Denies use. Caffeine: Drinks 2–3 cups of tea daily, often in the evening. Exercise: Walks 20 minutes 3–4 times/week, limited by knee pain.
awakenings (3–4 times/night), and unrefreshing sleep (4–5 hours/night), resulting in daytime fatigue, irritability, and impaired concentration. Symptoms began after her spouse’s death and are exacerbated by stress, evening caffeine, and irregular sleep habits. She uses diphenhydramine PRN with limited benefit and morning grogginess. PMH includes controlled hypertension and osteoarthritis. Social history reveals recent bereavement, social isolation, and evening screen time. She denies neurological or psychiatric diagnoses but reports low mood and anxiety.
Ears: Tympanic membranes clear bilaterally. Nose: No congestion or discharge. Throat: Pharynx clear, no erythema or tonsillar enlargement. Neck Supple, full range of motion, no stiffness or meningismus. No thyroid enlargement or nodules. No cervical lymphadenopathy. Neurological Mental Status: Alert and oriented x3. Normal speech, appropriate affect, though mildly anxious. No cognitive deficits on mini-mental status exam (MMSE: 29/30). Cranial Nerves: II–XII intact. No facial asymmetry or sensory deficits. Motor: 5/5 strength in all extremities, no tremors. Sensory: Intact to light touch, pinprick, and vibration. Coordination: Normal finger-to-nose and heel-to-shin tests. Reflexes: 2+ and symmetric (biceps, triceps, patellar, Achilles). Gait: Normal, no ataxia or Romberg sign. Cardiovascular Heart: Regular rate and rhythm, no murmurs, rubs, or gallops. Peripheral pulses: 2+ bilaterally (radial, dorsalis pedis). Respiratory Lungs: Clear to auscultation bilaterally, no wheezing or crackles. Respiratory effort: Normal, no accessory muscle use. Gastrointestinal
Probability: High due to chronicity, absence of organic causes, and clear psychosocial triggers. Insomnia Due to Adjustment Disorder with Depressed Mood Rationale: Insomnia onset coincides with spouse’s death, with associated low mood, anxiety, and tearfulness. Adjustment disorder with depressed mood can manifest as sleep disturbance in response to a major stressor. Probability: High, likely co-occurring with primary insomnia. Sleep Apnea (Obstructive or Central) Rationale: Older age and daytime fatigue raise concern for sleep apnea. However, no snoring, apneic episodes, or obesity (BMI 24.9) reported, making this less likely. Probability: Moderate, requires further evaluation if symptoms persist. Restless Legs Syndrome (RLS) Rationale: RLS can cause difficulty falling asleep due to leg discomfort. No reports of leg sensations or urge to move legs, reducing likelihood. Probability: Low, but worth exploring if sleep hygiene interventions fail. Thyroid Dysfunction (Hyperthyroidism) Rationale: Insomnia, anxiety, and fatigue could suggest hyperthyroidism, common in older adults. No weight loss, palpitations, or heat intolerance reported, lowering probability. Probability: Low, but thyroid tests warranted. Medication-Induced Insomnia (e.g., Lisinopril) Rationale: Lisinopril is not commonly associated with insomnia, and symptoms began long after its initiation, making this unlikely. Diphenhydramine overuse may contribute to grogginess rather than insomnia. Probability: Low, but medication review is prudent. Major Depressive Disorder (MDD)
Rationale: Low mood, fatigue, and insomnia could indicate MDD, but symptoms appear tied to grief and lack chronicity or severity for a full MDD diagnosis. Probability: Low, though adjustment disorder is more fitting. Neurological Disorder (e.g., Early Dementia) Rationale: Insomnia and mild cognitive complaints (concentration issues) could suggest early neurodegenerative disease, but normal MMSE and neurological exam make this unlikely. Probability: Very low, included for completeness.