,Patient Information
Name: Margaret Johnson (per iHuman case documentation)
Age: 65 years
Gender: Female
Height: 5’2” (157.5 cm, approximately 25th percentile for age)
Weight: 145 lb (65.8 kg, BMI 26.5 kg/m², classified as overweight)
Reason for Encounter: Difficulty sleeping for the past 3 months,
presenting to a primary care clinic in 2024 for evaluation.
History of Present Illness
Margaret Johnson, a 65-year-old widowed female, presents to the
primary care clinic with a chief complaint of trouble sleeping for the
past 3 months. She describes a combination of initial insomnia (taking
1-2 hours to fall asleep) and maintenance insomnia (waking 3-4 times
per night with difficulty returning to sleep). She estimates sleeping only
4-5 hours per night, compared to her previous baseline of 7-8 hours.
The sleep disturbances occur at least 4 nights per week and have
progressively worsened, leading to significant daytime consequences.
She reports feeling fatigued, with low energy that impacts her ability to
perform daily tasks, such as grocery shopping or household chores. She
also notes difficulty concentrating (e.g., forgetting items on her to-do
, list) and increased irritability, which has strained interactions with her
sister and friends. She denies excessive daytime sleepiness, such as
falling asleep during conversations or while driving, but feels “drained”
by mid-afternoon. The patient associates the onset of her sleep issues
with the death of her husband 6 months ago from a sudden heart
attack, a significant life stressor. She describes ongoing grief, with
episodes of low mood, tearfulness, and a loss of interest in previously
enjoyed activities, such as gardening and reading. She occasionally feels
hopeless about the future, stating, “I don’t know how to move forward
without him.” However, she denies suicidal ideation, plan, or intent,
and has not experienced hallucinations or significant weight changes,
though her appetite has slightly decreased. She denies snoring, gasping,
or witnessed apneas during sleep, and reports no leg twitching,
discomfort, or urge to move her legs at night. Margaret has tried over-
the-counter melatonin (3 mg, taken 30 minutes before bedtime) for the
past month with minimal improvement. She avoids alcohol,
recreational drugs, and prescription sleep aids due to concerns about
dependency and side effects. Her caffeine intake is limited to one cup
of coffee in the morning, and she avoids caffeine after noon. She denies
recent changes in medications, new medical conditions, or
environmental factors (e.g., noisy bedroom, new bedding). Her bedtime
routine includes watching television or scrolling on her phone, which
Name: Margaret Johnson (per iHuman case documentation)
Age: 65 years
Gender: Female
Height: 5’2” (157.5 cm, approximately 25th percentile for age)
Weight: 145 lb (65.8 kg, BMI 26.5 kg/m², classified as overweight)
Reason for Encounter: Difficulty sleeping for the past 3 months,
presenting to a primary care clinic in 2024 for evaluation.
History of Present Illness
Margaret Johnson, a 65-year-old widowed female, presents to the
primary care clinic with a chief complaint of trouble sleeping for the
past 3 months. She describes a combination of initial insomnia (taking
1-2 hours to fall asleep) and maintenance insomnia (waking 3-4 times
per night with difficulty returning to sleep). She estimates sleeping only
4-5 hours per night, compared to her previous baseline of 7-8 hours.
The sleep disturbances occur at least 4 nights per week and have
progressively worsened, leading to significant daytime consequences.
She reports feeling fatigued, with low energy that impacts her ability to
perform daily tasks, such as grocery shopping or household chores. She
also notes difficulty concentrating (e.g., forgetting items on her to-do
, list) and increased irritability, which has strained interactions with her
sister and friends. She denies excessive daytime sleepiness, such as
falling asleep during conversations or while driving, but feels “drained”
by mid-afternoon. The patient associates the onset of her sleep issues
with the death of her husband 6 months ago from a sudden heart
attack, a significant life stressor. She describes ongoing grief, with
episodes of low mood, tearfulness, and a loss of interest in previously
enjoyed activities, such as gardening and reading. She occasionally feels
hopeless about the future, stating, “I don’t know how to move forward
without him.” However, she denies suicidal ideation, plan, or intent,
and has not experienced hallucinations or significant weight changes,
though her appetite has slightly decreased. She denies snoring, gasping,
or witnessed apneas during sleep, and reports no leg twitching,
discomfort, or urge to move her legs at night. Margaret has tried over-
the-counter melatonin (3 mg, taken 30 minutes before bedtime) for the
past month with minimal improvement. She avoids alcohol,
recreational drugs, and prescription sleep aids due to concerns about
dependency and side effects. Her caffeine intake is limited to one cup
of coffee in the morning, and she avoids caffeine after noon. She denies
recent changes in medications, new medical conditions, or
environmental factors (e.g., noisy bedroom, new bedding). Her bedtime
routine includes watching television or scrolling on her phone, which
