,Patient Information
Name: Margaret Johnson (per iHuman case documentation)
Age: 65 years
Gender: Female
Height: 5’2” (157.5 cm)
Weight: 145 lb (65.8 kg, BMI 26.5 kg/m², classified as overweight)
Reason for Encounter: Trouble sleeping for the past 3 months,
presenting to a primary care clinic in 2024.
History of Present Illness
Margaret Johnson, a 65-year-old female, presents to the primary care
clinic with a chief complaint of difficulty sleeping for the past 3 months.
She describes trouble falling asleep (initial insomnia), taking 1-2 hours
to fall asleep most nights, and frequent awakenings (maintenance
insomnia), with difficulty returning to sleep. She estimates sleeping 4-5
hours per night, compared to her usual 7-8 hours prior to symptom
onset. The patient reports feeling fatigued during the day, with
difficulty concentrating and increased irritability, which are affecting
her quality of life and social interactions. She denies excessive daytime
sleepiness or falling asleep unintentionally during the day. Associated
symptoms include low mood, decreased interest in hobbies (e.g.,
, gardening, reading), and occasional feelings of hopelessness,
particularly since her husband’s death 6 months ago. She denies
suicidal ideation, hallucinations, or significant weight changes, though
she notes a slight decrease in appetite. She reports no snoring, gasping,
or witnessed apneas during sleep, and no leg twitching or discomfort at
night. She denies recent stressors other than ongoing grief, no new
medications, and no changes in caffeine or alcohol intake. She has tried
over-the-counter melatonin (3 mg) without significant improvement
and avoids sleep aids due to concerns about dependency. Medical
History
Past Medical History:
Hypertension, diagnosed 10 years ago, controlled with
hydrochlorothiazide 25 mg daily.
Osteoarthritis, managed with acetaminophen as needed.
No history of depression, anxiety, sleep apnea, or thyroid
disorders.
Surgical History: Cholecystectomy at age 50, no complications.
Allergies: No known drug, food, or environmental allergies.
Medications:
Hydrochlorothiazide 25 mg daily (for hypertension).
Name: Margaret Johnson (per iHuman case documentation)
Age: 65 years
Gender: Female
Height: 5’2” (157.5 cm)
Weight: 145 lb (65.8 kg, BMI 26.5 kg/m², classified as overweight)
Reason for Encounter: Trouble sleeping for the past 3 months,
presenting to a primary care clinic in 2024.
History of Present Illness
Margaret Johnson, a 65-year-old female, presents to the primary care
clinic with a chief complaint of difficulty sleeping for the past 3 months.
She describes trouble falling asleep (initial insomnia), taking 1-2 hours
to fall asleep most nights, and frequent awakenings (maintenance
insomnia), with difficulty returning to sleep. She estimates sleeping 4-5
hours per night, compared to her usual 7-8 hours prior to symptom
onset. The patient reports feeling fatigued during the day, with
difficulty concentrating and increased irritability, which are affecting
her quality of life and social interactions. She denies excessive daytime
sleepiness or falling asleep unintentionally during the day. Associated
symptoms include low mood, decreased interest in hobbies (e.g.,
, gardening, reading), and occasional feelings of hopelessness,
particularly since her husband’s death 6 months ago. She denies
suicidal ideation, hallucinations, or significant weight changes, though
she notes a slight decrease in appetite. She reports no snoring, gasping,
or witnessed apneas during sleep, and no leg twitching or discomfort at
night. She denies recent stressors other than ongoing grief, no new
medications, and no changes in caffeine or alcohol intake. She has tried
over-the-counter melatonin (3 mg) without significant improvement
and avoids sleep aids due to concerns about dependency. Medical
History
Past Medical History:
Hypertension, diagnosed 10 years ago, controlled with
hydrochlorothiazide 25 mg daily.
Osteoarthritis, managed with acetaminophen as needed.
No history of depression, anxiety, sleep apnea, or thyroid
disorders.
Surgical History: Cholecystectomy at age 50, no complications.
Allergies: No known drug, food, or environmental allergies.
Medications:
Hydrochlorothiazide 25 mg daily (for hypertension).
