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

Patient History (PH) – Diana Walters (65 y/o Female)

Course: Class 6531 – Week # Case Focus: Insomnia & Emotional Distress

Chief Complaint (CC):

“I haven’t been sleeping well for the past few months.”

History of Present Illness (HPI):

• Trouble sleeping for the past 6 months , gradually worsening
• Difficulty falling asleep (takes 1–2 hours) and staying asleep (wakes between 3–4 AM)
• Reports light, non-restorative sleep
• Daytime fatigue , low motivation, and reduced social interaction
• No nightmares, snoring, nocturia, or pain interrupting sleep
• Denies hallucinations, suicidal ideation, or panic attacks
• Denies caffeine use after 3 PM, no alcohol or smoking
• Grieving loss of close friend 9 months ago
• Tried OTC melatonin and tea – minimal effect
• Frequently uses tablet/TV in bed before sleep
• Concerned about the impact of poor sleep on health and mood

Past Medical History (PMH):

• Hypertension – well-controlled on lisinopril
• Hyperlipidemia – managed with atorvastatin
• Mild osteoarthritis – occasional knee pain
• No previous psychiatric diagnosis
• No diagnosed sleep disorder

Past Surgical History (PSH):

• No previous surgeries reported

Family History (FH):

• Mother: Died age 83 – stroke
• Father: Died age 80 – type 2 diabetes
• No family history of mental illness or sleep disorders

Social History (SH):

• Marital status: Married, lives with spouse
• Occupation: Retired school teacher
• Tobacco: Never smoked
• Alcohol: Denies use
• Illicit Drugs: Denies use
• Caffeine: One cup daily in the morning only
• Diet: Balanced, home-cooked meals
• Exercise: Walks 3x/week
• Sleep routine: Irregular bedtime habits; uses screens in bed
• Support system: Attends church, limited social contact since friend's death

OB/GYN History (GYN/OG):

• Menopause: Completed, no hormone replacement
• No recent gynecological concerns
• Gravida 2, Para 2 – two full-term births
• No history of gynecologic surgery or cancers Here is the complete Physical Examination (PE) section for the i-Human Week #9 Case (65- year-old female presenting with insomnia), organized into professional bullet format — including General Examination, Vital Signs, Head, and Sensory Organs (HEENT) as requested:

Physical Examination (PE) – Diana Walters (65 y/o

Female)

Ears:

• External ear normal, no tenderness or discharge
• Tympanic membranes intact and pearly gray bilaterally
• No hearing loss or tinnitus reported Nose:
• Nasal mucosa pink and moist
• No congestion, discharge, or nasal polyps
• No septal deviation Throat/Mouth:
• Oral mucosa moist and pink
• No lesions or thrush
• No erythema or exudate in oropharynx
• Teeth in good condition, no dental caries Here is a clear and professional Summary of Important and Relevant Findings for the i- Human Week #9 Case Study: 65 - Year-Old Female – Primary Complaint: Insomnia

Summary of Relevant Clinical Findings

Patient Profile

• Name: Diana Walters
• Age: 65
• Sex: Female
• Occupation: Retired schoolteacher
• Setting: Outpatient clinic
• Visit Type: Routine evaluation of chronic sleep disturbance

Chief Complaint

“I haven’t been sleeping well for the past few months.”

History of Present Illness (HPI)

• Trouble falling asleep (1–2 hours latency)
• Early morning awakening (3–4 a.m.)
• Feels tired and unrefreshed on waking
• Duration: 6 months, gradually worsening
• Denies snoring, nocturia, pain, or nightmares
• Sleep disruption began after loss of close friend 9 months ago
• Reports low energy, sadness, emotional withdrawal
• No suicidal ideation, psychosis, or mania
• Uses tablet/TV before bed , sometimes naps in the day
• Tried melatonin and tea without relief

Past Medical History

• Hypertension
• Hyperlipidemia
• Mild osteoarthritis
• No psychiatric history
• Menopause completed, no current gynecologic concerns

Social History

• Retired, lives with spouse
• Non-smoker, no alcohol or drug use
• Attends church; recent social withdrawal
• Fair nutrition, walks 3x per week
• Increased isolation since bereavement

Physical Exam Findings

• Vitals: Stable and within normal limits
• General: Alert, oriented, mildly fatigued
• HEENT: Normal, no signs of infection or inflammation
• Neuro: No deficits, A&O ×
• Psych: Flat affect, mildly low mood, cooperative
• No signs of acute medical or psychiatric illness

Differential Diagnoses

# Diagnosis Reasoning 1 Adjustment Disorder with Depressed Mood (F43.21) Strong psychosocial stressor (loss of close friend), emotional withdrawal, sadness, but symptoms do not meet full MDD criteria. Sleep disturbance consistent with diagnosis. 2 Major Depressive Disorder (MDD) Possible due to flat affect and low mood; however, lacks core symptoms like anhedonia, appetite/weight change, suicidal ideation. PHQ-9 screening needed to rule in/out. 3 Generalized Anxiety Disorder (GAD) May contribute to sleep onset difficulty, but patient does not report excessive worry or physical signs of anxiety. GAD- 7 screening suggested. 4 Obstructive Sleep Apnea (OSA) Unlikely: no snoring, no daytime sleepiness, no obesity or witnessed apneas. Not the primary pattern of sleep complaint. 5 Grief Reaction (Uncomplicated Bereavement) Significant emotional loss present, but patient is not incapacitated; functioning is intact. Symptoms suggest adjustment disorder more than isolated bereavement. 6 Restless Legs Syndrome (RLS) No symptoms like leg discomfort or urge to move at rest; ruled out based on detailed sleep history.

Final Diagnosis

Primary Insomnia (G47.00)

• Sleep onset and maintenance issues lasting over 6 months
• No underlying medical, psychiatric, or substance-related cause
• Disrupted sleep pattern causing daytime fatigue
• Supported by normal physical exam, ROS, and history Adjustment Disorder with Depressed Mood (F43.21)
• Directly related to death of a close friend
• Patient displays mild depressive symptoms (fatigue, social withdrawal, sadness)
• Does not meet criteria for Major Depressive Disorder but requires supportive care and monitoring Here is the complete and clinically appropriate section for:

Relevant and Important Investigations & Results

Patient: Diana Walters (65-year-old female) Case: Week #9 – i-Human Case (Insomnia & Emotional Distress)

Laboratory Investigations Ordered

Test Reason Result Interpretation CBC (Complete Blood Count) Rule out anemia or infection as a cause of fatigue Normal No anemia or infection contributing to symptoms TSH (Thyroid Stimulating Hormone) Evaluate for hypothyroidism (a common cause of fatigue and sleep issues) Within normal limits Thyroid dysfunction ruled out Vitamin B Rule out deficiency that may cause fatigue or cognitive effects Normal No neurological/vitamin deficiency impact Vitamin D Fatigue and mood regulation Low- Normal Not severely deficient, but could benefit from supplementation PHQ- 9 (Depression Screen) Assess for Major Depressive Disorder Mild depression range (score ~6–9) Suggestive of Adjustment Disorder rather than MDD GAD-7 (Anxiety Screen) Evaluate for anxiety component Low score (0–4) Anxiety is not a significant contributor

Optional/Deferred Investigations (Not Initially Required)

Test Reason Status Polysomnography (Sleep Study) To rule out OSA or parasomnias Not indicated — no snoring, apnea, or daytime hypersomnolence MMSE or MoCA (Cognitive Testing) Rule out early dementia in older patients Not indicated — no memory or cognitive complaints Serum Iron, Ferritin To assess for restless legs syndrome Not indicated — no RLS symptoms present

Summary of Key Results

• No medical cause (e.g., hypothyroidism, anemia) found for her fatigue or insomnia
• PHQ-9 supports mild depression , consistent with adjustment disorder
• No anxiety or neurological impairment identified

If Present Action Suicidal ideation, severe depression Immediate referral to mental health services or crisis intervention unit Medication overdose or reaction Emergency services; monitor for confusion, dizziness, hypotension Acute sleep deprivation causing falls, confusion Immediate safety plan, remove fall hazards, monitor vitals, consider short-term supervised care Emergency not currently present , but patient should be instructed to report:

• Worsening depression
• Hopelessness
• Confusion or severe side effects from medication

3. Treatment Plan

Pharmacologic: Drug Dose Use Notes Trazodone 25 – 50 mg PO at bedtime Short-term sleep aid Sedating antidepressant; preferred in elderly due to low abuse potential Acetaminophen 500 mg PRN Mild knee pain May improve sleep if pain is contributing factor Avoid benzodiazepines, diphenhydramine, zolpidem in older adults (Beers Criteria risk: falls, confusion, dependence) Non-Pharmacologic:

• CBT-I referral (Cognitive Behavioral Therapy for Insomnia) – gold-standard treatment
• Sleep diary – patient tracks sleep and wake times for 2 weeks
• Grief counseling – referral to licensed therapist or social worker
• PHQ-9 follow-up – monitor for progression to major depressive disorder

4. Doctor’s Ongoing Plan

Plan Component Detail Follow-Up Visit In 4 weeks to assess sleep, mood, medication effect, therapy engagement Monitoring Watch for depression worsening (repeat PHQ-9), medication tolerance, or new symptoms Adjustments Taper medication if sleep improves Switch or escalate if no benefit from trazodone Lab Results Review CBC, TSH, B12, Vit D — address deficiencies if found Mental Health Referral If PHQ-9 increases or patient expresses distress, refer to psychiatry for co-management

Summary

Diagnosis:

• Primary Insomnia (G47.00)
• Adjustment Disorder with Depressed Mood (F43.21) Goal: Restore healthy sleep, improve mood, and prevent deterioration into major depression — using a multimodal, low-risk plan tailored to an older adult. Here is a clear, concise, and clinically appropriate section on:

Relevant Advice to the Patient

Patient: Diana Walters, 65-year-old female Concern: Chronic insomnia and emotional distress

1. Sleep Hygiene Advice

These daily habits can help you fall asleep faster and stay asleep longer:

5. Next Steps

• Return for follow-up in 4 weeks
• Bring your sleep diary to review patterns and progress
• Complete your lab tests and mental health screenings as instructed Remember: Your sleep can improve with consistent care, support, and lifestyle changes. You are not alone, and we're here to help. Here is a professionally written and exam-ready Reflection Report for the i-Human Week # Case Study: Diana Walters – 65 - Year-Old Female with Insomnia and Emotional Distress

🪞 Reflection Report

Course: Class 6531 Case Study: Week #9 – Diana Walters (65 y/o Female with Insomnia) Student: [Your Name] Date: [Insert Date]

1. What Did I Learn from This Case?

This case deepened my understanding of how insomnia in older adults often stems from complex biopsychosocial factors—not just sleep behaviors. I learned how grief, emotional distress, and lifestyle habits can influence sleep, and how insomnia may present as the primary symptom of adjustment disorder or even unrecognized depression. Importantly, I saw the role of non-pharmacologic approaches such as Cognitive Behavioral Therapy for Insomnia (CBT-I), as well as the need for caution in prescribing medications to older adults due to fall and cognitive risks.

2. What Went Well?

• I accurately identified the chief complaint and formulated relevant differentials , including primary insomnia, adjustment disorder, and major depression.

• I understood the importance of screening tools like PHQ-9 and GAD-7 in determining emotional contributions to sleep problems.
• I applied evidence-based treatment strategies including recommending CBT-I, sleep hygiene, and a low-dose of trazodone—safe for elderly patients.

3. What Could I Improve?

Initially, I leaned too heavily on pharmacologic treatment without first prioritizing behavioral interventions , which are the true first-line treatment for chronic insomnia. I also realized I needed to ask more about functional impact , such as whether insomnia was affecting safety (e.g., driving or falls), which is critical in elderly patients. Next time, I would also explore the grief process more deeply , as bereavement can mask depressive symptoms and complicate sleep.

4. How Will This Influence My Future Practice?

This case reminded me to always approach insomnia holistically— never treat sleep complaints in isolation. I will screen all older patients with insomnia for emotional distress, depression, anxiety, and grief. I also gained confidence in choosing safer pharmacological alternatives for elderly clients and in counseling on sleep hygiene in practical, empathetic terms. I’ll be more deliberate in recommending CBT-I as a gold standard therapy and in identifying when specialist referrals (mental health, sleep medicine) are appropriate.

5. Key Takeaway

Insomnia is not just a nighttime problem — it is often a daytime reflection of unresolved emotions, poor habits, or unrecognized illness. Compassionate listening, cautious prescribing, and evidence-based behavioral therapy are key.