iHuman Case Study: 65-Year-Old Female Patient Presenting with Trouble Sleeping (Class 65, Exams of Integrated Case Studies

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iHuman Case Study: 65-Year-Old Female

Patient Presenting with Trouble Sleeping

(Class 6531) - Week

✔✔ doctor’s answer ✔✔When did your trouble sleeping start?

✔✔ patient’s answer ✔✔ “It started about six months ago, right after my husband

passed away. It’s gotten worse over time.”

✔✔ doctor’s answer ✔✔Was the onset sudden or gradual?

✔✔ patient’s answer ✔✔ “It was gradual. At first, I had trouble sleeping a few

nights a week, but now it’s almost every night.” Location

✔✔ doctor’s answer ✔✔Is there a specific part of your sleep process that’s

affected, like falling asleep or staying asleep?

✔✔ patient’s answer ✔✔ “Both. It takes me a long time to fall asleep, and I wake

up several times during the night.” Duration

✔✔ doctor’s answer ✔✔How long does it take you to fall asleep?

✔✔ patient’s answer ✔✔ “It usually takes 30 to 60 minutes to fall asleep.”

✔✔ doctor’s answer ✔✔How many hours of sleep do you get each night?

✔✔ patient’s answer ✔✔ “I’m only getting about 4 to 5 hours of sleep a night.”

✔✔ doctor’s answer ✔✔How long do you stay awake during these nighttime

awakenings?

✔✔ patient’s answer ✔✔ “Sometimes 20–30 minutes, sometimes longer. I often

can’t get back to sleep easily.” Characteristics

✔✔ doctor’s answer ✔✔Can you describe what it feels like when you can’t sleep?

✔✔ patient’s answer ✔✔ “I lie awake worrying, and my mind won’t shut off. I feel

restless and frustrated.”

✔✔ doctor’s answer ✔✔Do you feel refreshed when you wake up?

✔✔ patient’s answer ✔✔ “No, I feel exhausted and unrefreshed, like I haven’t slept

at all.”

✔✔ doctor’s answer ✔✔On a scale of 0 to 10, how severe is the impact of your

sleep problems on your daily life?

✔✔ patient’s answer ✔✔ “I’d say a 7 out of 10. It’s making it hard to focus, and

I’m irritable all the time.” Aggravating Factors

✔✔ doctor’s answer ✔✔What makes your trouble sleeping worse?

✔✔ patient’s answer ✔✔ “Stress makes it worse, especially thinking about my

husband’s death. Also, drinking tea in the evening or watching TV late at night.”

✔✔ doctor’s answer ✔✔Do any specific activities or environments affect your

sleep?

✔✔ patient’s answer ✔✔ “Using my tablet before bed seems to keep me up. Bright

lights or noise at night make it harder to sleep.” Relieving Factors

✔✔ doctor’s answer ✔✔What helps you sleep better?

✔✔ patient’s answer ✔✔ “Sometimes taking Benadryl helps a little, but it makes

me groggy the next day. Reading a book or relaxing in a quiet room can help me calm down.”

✔✔ doctor’s answer ✔✔Have you tried any other remedies or techniques?

✔✔ patient’s answer ✔✔ “I’ve tried chamomile tea a few times, but it didn’t make

much difference.” Timing

✔✔ doctor’s answer ✔✔How often do you have trouble sleeping?

✔✔ patient’s answer ✔✔ “Not that I know of. Nobody’s told me I snore, and I live

alone now.”

✔✔ doctor’s answer ✔✔Have you noticed changes in your mood or energy?

✔✔ patient’s answer ✔✔ “Yes, I’m more irritable and feel low a lot. I don’t have

the energy I used to.” Past Medical History (PMH)

✔✔ doctor’s answer ✔✔Do you have any past or current medical conditions?

✔✔ patient’s answer ✔✔ “I have high blood pressure, diagnosed about 10 years

ago, and osteoarthritis in my knees.”

✔✔ doctor’s answer ✔✔Have you ever had sleep problems before, like insomnia or

sleep apnea?

✔✔ patient’s answer ✔✔ “No, this is the first time I’ve had trouble sleeping like

this.”

✔✔ doctor’s answer ✔✔Have you had any neurological conditions, like seizures or

Parkinson’s?

✔✔ patient’s answer ✔✔ “No, nothing like that.”

✔✔ doctor’s answer ✔✔Have you ever been diagnosed with a mental health

condition, like depression or anxiety?

✔✔ patient’s answer ✔✔ “No, but I’ve been feeling anxious and down since my

husband passed.”

✔✔ doctor’s answer ✔✔Have you had any recent hospitalizations, surgeries, or

injuries?

✔✔ patient’s answer ✔✔ “No hospitalizations or surgeries. No injuries either.”

✔✔ doctor’s answer ✔✔Are your vaccinations up to date?

✔✔ patient’s answer ✔✔ “Yes, I got my flu shot this year and my pneumonia

vaccine a couple of years ago.” Medications

✔✔ doctor’s answer ✔✔What medications do you take, including over-the-counter

or supplements?

✔✔ patient’s answer ✔✔ “I take lisinopril 10 mg daily for my blood pressure,

acetaminophen 500 mg as needed for knee pain, and Benadryl 25 mg a couple of times a week for sleep.”

✔✔ doctor’s answer ✔✔How often do you take the Benadryl, and when did you

start it?

✔✔ patient’s answer ✔✔ “I started it about 3 months ago, and I take it 2 or 3

nights a week when I really can’t sleep.”

✔✔ doctor’s answer ✔✔Have you tried any other sleep aids or herbal remedies?

✔✔ patient’s answer ✔✔ “Just chamomile tea a few times, but it didn’t help

much.” Allergies

✔✔ doctor’s answer ✔✔Do you have any allergies to medications, foods, or other

things?

✔✔ patient’s answer ✔✔ “No, I don’t have any allergies.”

Social History (SH)

✔✔ doctor’s answer ✔✔What is your occupation, and how has your sleep issue

affected your work?

✔✔ patient’s answer ✔✔ “I’m a retired schoolteacher. I don’t work now, but the

tiredness makes it hard to stay active or do things I enjoy.”

✔✔ doctor’s answer ✔✔Do you smoke or use tobacco products?

Family History (FH)

✔✔ doctor’s answer ✔✔Do any family members have sleep problems, like

insomnia or sleep apnea?

✔✔ patient’s answer ✔✔ “Not that I know of. Nobody in my family has mentioned

sleep issues.”

✔✔ doctor’s answer ✔✔What medical conditions run in your family?

✔✔ patient’s answer ✔✔ “My mother had high blood pressure and died of a heart

attack at 80. My father had diabetes and passed at 75.”

✔✔ doctor’s answer ✔✔Any family history of mental health issues or neurological

disorders?

✔✔ patient’s answer ✔✔ “No, no one in my family has had depression, anxiety, or

things like Parkinson’s.” Review of Systems (ROS) General:

✔✔ doctor’s answer ✔✔Have you had any recent weight changes, fever, or chills?

✔✔ patient’s answer ✔✔ “No, my weight’s been stable, and I haven’t had any

fevers or chills.”

✔✔ doctor’s answer ✔✔Do you feel fatigued or low energy during the day?

✔✔ patient’s answer ✔✔ “Yes, I’m tired all day and don’t have much energy.”

Neurological:

✔✔ doctor’s answer ✔✔Do you have headaches, dizziness, or memory problems?

✔✔ patient’s answer ✔✔ “No headaches or dizziness, but I’ve noticed it’s harder

to concentrate since I’m not sleeping well.”

✔✔ doctor’s answer ✔✔Any seizures, weakness, or numbness?

✔✔ patient’s answer ✔✔ “No, none of those.”

Psychiatric:

✔✔ doctor’s answer ✔✔Have you felt depressed, anxious, or had thoughts of

harming yourself?

✔✔ patient’s answer ✔✔ “I’ve been feeling down and anxious since my husband

died, and I get tearful sometimes, but I don’t want to hurt myself.”

✔✔ doctor’s answer ✔✔Any changes in mood or behavior?

✔✔ patient’s answer ✔✔ “I’m more irritable than usual, and I don’t enjoy things

as much.” Cardiovascular:

✔✔ doctor’s answer ✔✔Any chest pain, palpitations, or swelling in your legs?

✔✔ patient’s answer ✔✔ “No chest pain or palpitations. No swelling either.”

Respiratory:

✔✔ doctor’s answer ✔✔Any shortness of breath, coughing, or wheezing?

✔✔ patient’s answer ✔✔ “No, my breathing’s fine.”

Gastrointestinal:

✔✔ doctor’s answer ✔✔Any nausea, vomiting, or changes in your bowel habits?

✔✔ patient’s answer ✔✔ “I get heartburn sometimes, but no nausea, vomiting, or

bowel changes.” Musculoskeletal:

✔✔ doctor’s answer ✔✔Any joint pain, stiffness, or muscle weakness?

✔✔ patient’s answer ✔✔ “My knees hurt from arthritis, but no new pain or

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.

2. Physical Examination (Objective Data) A focused physical exam was conducted to evaluate neurological, cardiovascular, and other systems relevant to insomnia and rule out organic causes. Vital Signs Blood Pressure: 128/82 mmHg (controlled on lisinopril) Heart Rate: 68 beats/min, regular Respiratory Rate: 14 breaths/min Temperature: 98.4°F (36.9°C) Oxygen Saturation: 97% on room air Height: 5’4” (162 cm) Weight: 145 lbs (66 kg) BMI: 24.9 kg/m² (normal) General Appearance Well-groomed, alert, no acute distress, appears fatigued with mild anxious affect. HEENT Head: Normocephalic, atraumatic, no scalp tenderness. Eyes: Pupils equal, round, reactive to light and accommodation (PERRLA). No nystagmus. Fundoscopic exam normal, no papilledema or retinal abnormalities.

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.

4. Diagnostic Testing Targeted tests are ordered to rule out secondary causes of insomnia and confirm the primary diagnosis, following American Academy of Sleep Medicine (AASM) and UpToDate guidelines. Complete Blood Count (CBC): Purpose: Rule out anemia or infection contributing to fatigue. Expected Result: Likely normal, given no systemic symptoms. Comprehensive Metabolic Panel (CMP): Purpose: Assess electrolytes, glucose, liver, and kidney function to exclude metabolic causes (e.g., hyponatremia, renal dysfunction). Expected Result: Likely normal, but monitors lisinopril effects. Thyroid Function Tests (TSH, Free T4): Purpose: Rule out hyperthyroidism (causing insomnia/anxiety) or hypothyroidism (causing fatigue). Expected Result: Likely normal, no thyroid symptoms reported. Serum Ferritin and Iron Studies: