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

• No known psychiatric history.
• No diagnosed sleep disorders.

Past Surgical History:

• None reported.

Medications:

• Lisinopril 10 mg PO daily – hypertension.
• Atorvastatin 20 mg PO at bedtime – hyperlipidemia.
• Acetaminophen 500 mg PRN – mild knee pain.

Allergies:

• No known drug allergies (NKDA).

Family History:

• Mother : Deceased at age 83 (stroke).
• Father : Deceased at age 80 (type 2 diabetes).
• No family history of psychiatric illness or sleep disorders.

Social History:

• Marital status : Married, lives with spouse.
• Occupation : Retired school teacher.
• Tobacco : Never smoker.
• Alcohol : Denies use.
• Drugs : Denies recreational drug use.
• Caffeine : One cup in the morning, none after 3 PM.
• Exercise : Walks 3x weekly, low-impact.
• Diet : Balanced, home-cooked meals.
• Sleep environment : Bedtime at 10 PM, uses screens in bed, no specific bedtime rituals.

Review of Systems (ROS):

General:

• Mild fatigue
• No weight changes or fever Neurological:
• No headaches, dizziness, weakness, or paresthesias Psychiatric:
• Low mood, fatigue, emotional dullness
• No hallucinations, mania, or suicidal ideation Cardiovascular:
• No chest pain, palpitations, or syncope Respiratory:
• No SOB, cough, or wheezing Gastrointestinal:
• Normal appetite, no N/V/D or abdominal pain Genitourinary:
• No dysuria, frequency, or nocturia Musculoskeletal:
• Mild knee pain, especially with overuse Endocrine:
• No polyuria, polydipsia, or cold/heat intolerance

• Supple, full range of motion
• No lymphadenopathy or thyromegaly

Cardiovascular

• Regular rate and rhythm
• No murmurs, gallops, or rubs
• No carotid bruits
• Peripheral pulses intact and equal bilaterally
• No peripheral edema

Respiratory

• Clear to auscultation bilaterally
• No wheezing, crackles, or rhonchi
• No increased work of breathing

Gastrointestinal

• Abdomen soft, non-tender, non-distended
• Normoactive bowel sounds
• No hepatosplenomegaly
• No masses or bruits

Musculoskeletal

• Mild crepitus in bilateral knees
• No joint swelling or deformity
• Full range of motion in all extremities

Neurological

• Alert and oriented ×3 (person, place, time)
• Cranial nerves II–XII grossly intact
• No focal deficits

• Normal strength, reflexes, and gait
• No tremors or ataxia

Psychiatric

• Appropriate appearance and grooming
• Mood: “A bit down”
• Affect: Flat
• Behavior: Calm, cooperative
• Thought process: Linear, goal-directed
• No hallucinations, delusions, or suicidal ideation Here is the Assessment section for the i-Human Week #9 case study (65-year-old female presenting with trouble sleeping), formatted in clean, exam-ready bullet style :

ASSESSMENT

Patient: Diana Walters | Age: 65 years Chief Complaint: Difficulty sleeping for the past 6 months

Summary of Clinical Findings

• Difficulty falling and staying asleep for 6 months
• Wakes early and cannot return to sleep
• Mild daytime fatigue and sadness
• No history of psychiatric illness
• Recent psychosocial stressor: death of a close friend
• No signs of medical or neurological causes
• No alcohol, caffeine, or substance abuse
• No evidence of obstructive sleep apnea or restless legs syndrome
• Physical exam: Unremarkable except mild fatigue and flat affect
• ROS: Negative for major psychiatric, cardiac, respiratory, or endocrine symptoms

Working Diagnosis

Insomnia

• This is the NANDA-approved nursing diagnosis.
• It refers to difficulty falling asleep, staying asleep, or waking too early , leading to daytime impairment such as tiredness, reduced function, or mood changes.
• In this case, the patient clearly describes difficulty initiating and maintaining sleep , consistent with chronic insomnia.

2. Etiology (Related To):

Related to emotional distress secondary to bereavement and poor sleep hygiene

• This part identifies the underlying cause or contributing factors to the problem.
• In this case: o The death of a close friend 9 months ago has caused significant grief and emotional disruption. o The patient also uses her tablet in bed and lacks a structured bedtime routine, both of which are poor sleep hygiene practices that affect sleep quality.

3. Signs/Symptoms (As Evidenced By):

As evidenced by:

• Prolonged sleep latency (takes 1–2 hours to fall asleep most nights)
• Early morning awakening (wakes up between 3:00–4:00 a.m. and cannot return to sleep)
• Daytime fatigue and reduced motivation
• Verbal expression of poor, non-restorative sleep This section documents the observable evidence or subjective/objective data that support the diagnosis. In this patient, both subjective symptoms (self-reported trouble sleeping, low energy) and clinical signs (fatigued appearance, flat affect) support the diagnosis of insomnia.

SECONDARY DIAGNOSIS (Optional but Useful for

Planning Care):

Risk for depression related to unresolved grief and persistent insomnia.

• Although the patient doesn’t meet full criteria for major depressive disorder, she is showing early emotional blunting , social withdrawal, and low mood.
• These signs indicate a potential progression to a clinical depressive disorder if untreated.

Why This Diagnosis Is Appropriate:

• This nursing diagnosis accurately describes what the patient is experiencing: ongoing sleep disruption, daytime consequences, emotional distress , and known sleep hygiene issues.
• It includes both psychological (grief/emotion) and behavioral (bedtime habits) contributors.
• The "as evidenced by" portion aligns with data gathered during the HPI, physical exam, and psychosocial assessment.

Exam Tips on Writing a Nursing Diagnosis:

Component What It Answers Example Problem What’s wrong? Insomnia Etiology Why is it happening? Related to grief, poor sleep hygiene Signs/Symptoms How do you know? As evidenced by difficulty sleeping, fatigue, etc. NANDA diagnosis + Related to + As evidenced by = perfect format for exams and care plans. Here is a complete and well-organized Nursing Care Plan for the i-Human Week #9 case study ( 65 - year-old female with insomnia ), including goals, nursing interventions, and rationales , based on the primary nursing diagnosis:

Nursing Care Plan – Diagnosis: Insomnia

Nursing Diagnosis:

Insomnia related to emotional distress and poor sleep hygiene as evidenced by prolonged sleep latency, early morning awakening, fatigue, and verbal report of poor sleep quality.

Outcome How to Measure Success Sleep duration Patient reports ≥ 6 hours of sleep per night consistently. Sleep latency Patient falls asleep within 30–45 minutes on most nights. Fatigue Patient verbalizes improved daytime energy and concentration. Mood Patient demonstrates improved mood and interest in daily activities. Here is the complete and professionally written SOAP Note for the i-Human Week #9 Case Study: 65 - Year-Old Female with Insomnia and Emotional Distress

SOAP NOTE – DIANA WALTERS (65 y/o Female)

Week #9 – i-Human Case | Class 6531 Chief Complaint: “I haven’t been sleeping well for months.”

S – Subjective

Patient Info:

• 65 - year-old retired female
• Presents with progressive difficulty sleeping over the last 6 months
• Reports trouble falling asleep (1–2 hours latency) and early morning awakenings (3– 4 a.m.)
• Describes sleep as light and unrefreshing , resulting in daytime fatigue
• Sometimes takes short afternoon naps
• Tried melatonin and herbal teas with little success
• Denies snoring, gasping, nocturia, or nightmares
• Increased stress and sadness after the death of a close friend 9 months ago
• Denies suicidal ideation, hallucinations, or substance use
• Admits to feeling more down, emotionally flat , and withdrawn from activities
• Uses tablet/TV before bedtime
• No caffeine after 3 PM , no alcohol or tobacco use
• Wants non-drug options , open to short-term medication

O – Objective

Vital Signs:

• BP: 128/76 mmHg
• HR: 72 bpm
• RR: 14 breaths/min
• Temp: 98.4°F
• BMI: 26. Physical Exam Findings:
• General: Alert, cooperative, slightly fatigued
• Neuro: A&O ×3, no focal deficits
• HEENT, CV, Resp, GI: Unremarkable
• Musculoskeletal: Mild crepitus in knees
• Psych: Flat affect, low mood, no psychosis, logical thought process Medications:
• Lisinopril 10 mg PO daily
• Atorvastatin 20 mg PO at bedtime
• Acetaminophen 500 mg PRN

A – Assessment

Primary Diagnosis:

• Primary Insomnia (G47.00) – Difficulty initiating and maintaining sleep with daytime impairment; chronic >6 months
• Adjustment Disorder with Depressed Mood (F43.21) – Emotional distress triggered by recent loss; low mood and sleep disturbance without full MDD criteria Differential Diagnoses:

1. Major Depressive Disorder (rule out via PHQ-9)
2. Generalized Anxiety Disorder (GAD-7 to screen)
3. Grief reaction
4. Sleep apnea – unlikely based on history
5. Restless legs syndrome – no suggestive symptoms

P – Plan

2. Adjustment Disorder with Depressed Mood (ICD-10: F43.21)

1. Pharmacologic Management

Medication Dosage Purpose Notes Trazodone 25 – 50 mg PO at bedtime PRN Sedating antidepressant used off-label for insomnia Preferred in elderly due to fewer anticholinergic and dependence risks compared to benzodiazepines Acetaminophen 500 mg PRN For mild osteoarthritis pain that may interfere with sleep Ensure pain is not disrupting sleep onset Avoid : Benzodiazepines, diphenhydramine, zolpidem — increased risk of falls, cognitive impairment in elderly (Beers Criteria).

2. Non-Pharmacologic Management

Strategy Description Rationale Cognitive Behavioral Therapy for Insomnia (CBT-I) Refer to licensed therapist or sleep psychologist First-line treatment for chronic insomnia per guidelines Grief Counseling / Therapy Referral to a counselor or mental health provider Address unresolved grief, emotional distress contributing to insomnia Sleep Diary Patient records bedtime, wake time, interruptions, naps Helps track patterns and evaluate treatment effectiveness Sleep Hygiene Education Teach patient best practices:

• Regular sleep/wake time
• Avoid screens ≥1 hr before bed
• No caffeine after 2 PM
• Use bed only for sleep/sex
• Create dark, quiet sleep environment
• Limit daytime naps | | Promote lifestyle structure | Encourage light exercise during the day (e.g., walking) | Enhances natural sleep rhythm |

3. Diagnostic & Screening Tests

Test Purpose PHQ-9 (Patient Health Questionnaire) Screen for depression GAD- 7 Screen for anxiety TSH, Vitamin B12, CBC, Vitamin D Rule out fatigue/insomnia causes (e.g., hypothyroidism, anemia, B12 deficiency) Sleep diary Non-invasive tracking of sleep habits over time Polysomnography (sleep study) Only if clinical suspicion of sleep apnea or if insomnia persists despite interventions

4. Follow-Up Plan

• Follow-up visit in 3–4 weeks to assess: o Response to trazodone o Sleep improvements via sleep diary o Mood changes o Medication side effects
• Reinforce CBT-I participation and sleep hygiene practices
• Adjust pharmacologic approach if no improvement or side effects occur

5. Patient Education

Topic Key Teaching Points Sleep Hygiene Avoid screens, caffeine, heavy meals, and irregular sleep schedules Medication Use Trazodone is short-term; avoid OTC sleep aids like Benadryl Grief Grieving is normal; support groups and counseling are available Safety Get out of bed slowly, especially if medicated (fall risk) When to Report Worsening mood, suicidal thoughts, confusion, adverse drug effects

Plan Summary (SOAP-style)

• S: Reports chronic insomnia, low energy, poor sleep habits
• O: Flat affect, tired appearance, normal vitals
• A: Primary insomnia + adjustment disorder with depressed mood
• P: Initiate trazodone, CBT-I referral, grief counseling, labs, and follow-up in 4 weeks

• Go to bed and wake up at the same time every day (even weekends).
• Keep your bedroom quiet, dark, and cool.
• Avoid screen time (TV, tablet, phone) for 1 hour before bed.
• Do something calming before bed: reading, light stretching, deep breathing.
• Avoid naps or keep them under 30 minutes and before 3 PM.
• Avoid caffeine (coffee, tea, soda, chocolate) after 2 PM. Healthy Routines:
• Walk or do gentle physical activity during the day.
• Eat light in the evening. Avoid heavy meals late at night.
• Talk about your feelings with a trusted person or therapist.

Medication Information (If Prescribed):

You may be prescribed Trazodone to help with sleep.

• Take it at bedtime, as directed.
• It may help you fall asleep easier and stay asleep longer.
• Common side effects: dizziness, drowsiness in the morning.
• Do not drive or operate machinery if you feel drowsy in the morning.

Other Resources to Help You

• Cognitive Behavioral Therapy for Insomnia (CBT-I): A safe, effective program that helps change negative sleep thoughts and behaviors.
• Grief Counseling: Talking to a counselor can help process loss and support emotional healing.

Follow-Up Plan

• You will return to the clinic in 4 weeks to check how your sleep is improving.
• Bring your sleep diary to track bedtime, wake time, and naps.
• We may adjust your plan based on how you're feeling.

Call Your Provider If:

• You feel worse emotionally or physically
• You experience dizziness, confusion, or frequent falls
• You feel overwhelmed or need additional support

Remember

You are not alone. Sleep issues are common, and they can improve with the right care and support. We’re here to help you rest better and feel better. Provider Signature: _______________________ Patient Signature (if printed): _______________________ Date: _______________________ Here is a professional and clinically sound Follow-Up Plan for the i-Human Week #9 Case: 65 - year-old female presenting with insomnia and emotional distress (Adjustment Disorder). This version is written in exam- and chart-ready language:

FOLLOW-UP PLAN – DIANA WALTERS (65 y/o

Female)

Follow-Up Visit:

• Scheduled in 4 weeks to: o Reassess sleep quality and quantity o Evaluate effectiveness and tolerance of Trazodone o Review sleep diary entries o Monitor for signs of depression or worsening emotional state o Ensure compliance with CBT-I or grief counseling if initiated

What Will Be Reviewed at the Follow-Up:

1. Sleep Diary Review: o Sleep onset latency o Number of night awakenings o Total hours of sleep