I-HUMAN Case Study Week 9: Comprehensive for a 65-Year-Old Female
with Chronic Insomnia (Trouble Sleeping) – CLASS 6531 Advanced Practice
Nursing
This in-depth I-HUMAN case study for Week 9 of CLASS 6531 presents a comprehensive for a 65-year-old
female experiencing chronic insomnia. The case includes a detailed history of present illness, full review of
systems, physical exam findings, differential diagnoses, evidence-based assessment, and a patient-centered
management plan emphasizing CBT-I and safe pharmacologic therapy for older adults.
• I-HUMAN case study
• Chronic insomnia case study
• Insomnia note
• CLASS 6531 Week 9
,2|Page
Course: CLASS 6531
Patient: 65-year-old Female
Diagnosis: Chronic Insomnia
Identifying Data
• Name: Mrs. J.D. (initials only)
• Age: 65 years
• Gender: Female
, • Ethnicity: Caucasian
• Marital Status: Widowed
• Occupation: Retired elementary school teacher
• Source of History: Patient (reliable)
• Date of Encounter: Week 9
Chief Complaint (CC)
“I can’t sleep at night. I’m lucky if I get 3 to 4 hours of sleep.”
History of Present Illness (HPI)
Mrs. J.D. is a 65-year-old female who presents with complaints of difficulty sleeping for the past 6 months.
She reports trouble falling asleep and staying asleep, waking multiple times throughout the night, and early
morning awakening around 3–4 a.m. She states her sleep difficulty occurs at least 5 nights per week and has
progressively worsened.
She describes lying awake for over an hour before falling asleep and waking up 3–4 times per night without
being able to return to sleep. She reports feeling fatigued, irritable, and unable to concentrate during the
day. She denies snoring, witnessed apnea, nocturnal choking, or gasping for air.
She reports increased stress since the death of her husband one year ago and admits to occasional daytime
napping. She drinks 2 cups of coffee daily, with one cup consumed in the late afternoon. She has tried over-
the-counter melatonin with minimal relief.
She denies chest pain, shortness of breath, nocturia, pain, restless legs, depression, or anxiety symptoms. No
recent medication changes.
Past Medical History (PMH)
• Hypertension – diagnosed 10 years ago
• Hyperlipidemia – diagnosed 8 years ago
• Osteoarthritis (knees)
Past Surgical History (PSH)
, 4|Page
• Total abdominal hysterectomy at age 45
• Appendectomy in childhood
Medications
• Lisinopril 20 mg PO daily
• Atorvastatin 20 mg PO nightly
• Acetaminophen 650 mg PO PRN for joint pain
• Melatonin 5 mg PO at bedtime (self-initiated)
Allergies
• No known drug allergies (NKDA)
Family History
• Father: Deceased at 78, myocardial infarction
• Mother: Deceased at 82, stroke
• Sister: Alive, type 2 diabetes
Social History
• Lives alone in a single-story home
• Widowed; good support from adult children
• Denies tobacco or illicit drug use
• Drinks wine occasionally (1 glass/week)
• Caffeine intake: 2 cups of coffee/day
• Exercises by walking 2–3 times per week
Review of Systems (ROS)
General: Fatigue, no fever or weight loss
with Chronic Insomnia (Trouble Sleeping) – CLASS 6531 Advanced Practice
Nursing
This in-depth I-HUMAN case study for Week 9 of CLASS 6531 presents a comprehensive for a 65-year-old
female experiencing chronic insomnia. The case includes a detailed history of present illness, full review of
systems, physical exam findings, differential diagnoses, evidence-based assessment, and a patient-centered
management plan emphasizing CBT-I and safe pharmacologic therapy for older adults.
• I-HUMAN case study
• Chronic insomnia case study
• Insomnia note
• CLASS 6531 Week 9
,2|Page
Course: CLASS 6531
Patient: 65-year-old Female
Diagnosis: Chronic Insomnia
Identifying Data
• Name: Mrs. J.D. (initials only)
• Age: 65 years
• Gender: Female
, • Ethnicity: Caucasian
• Marital Status: Widowed
• Occupation: Retired elementary school teacher
• Source of History: Patient (reliable)
• Date of Encounter: Week 9
Chief Complaint (CC)
“I can’t sleep at night. I’m lucky if I get 3 to 4 hours of sleep.”
History of Present Illness (HPI)
Mrs. J.D. is a 65-year-old female who presents with complaints of difficulty sleeping for the past 6 months.
She reports trouble falling asleep and staying asleep, waking multiple times throughout the night, and early
morning awakening around 3–4 a.m. She states her sleep difficulty occurs at least 5 nights per week and has
progressively worsened.
She describes lying awake for over an hour before falling asleep and waking up 3–4 times per night without
being able to return to sleep. She reports feeling fatigued, irritable, and unable to concentrate during the
day. She denies snoring, witnessed apnea, nocturnal choking, or gasping for air.
She reports increased stress since the death of her husband one year ago and admits to occasional daytime
napping. She drinks 2 cups of coffee daily, with one cup consumed in the late afternoon. She has tried over-
the-counter melatonin with minimal relief.
She denies chest pain, shortness of breath, nocturia, pain, restless legs, depression, or anxiety symptoms. No
recent medication changes.
Past Medical History (PMH)
• Hypertension – diagnosed 10 years ago
• Hyperlipidemia – diagnosed 8 years ago
• Osteoarthritis (knees)
Past Surgical History (PSH)
, 4|Page
• Total abdominal hysterectomy at age 45
• Appendectomy in childhood
Medications
• Lisinopril 20 mg PO daily
• Atorvastatin 20 mg PO nightly
• Acetaminophen 650 mg PO PRN for joint pain
• Melatonin 5 mg PO at bedtime (self-initiated)
Allergies
• No known drug allergies (NKDA)
Family History
• Father: Deceased at 78, myocardial infarction
• Mother: Deceased at 82, stroke
• Sister: Alive, type 2 diabetes
Social History
• Lives alone in a single-story home
• Widowed; good support from adult children
• Denies tobacco or illicit drug use
• Drinks wine occasionally (1 glass/week)
• Caffeine intake: 2 cups of coffee/day
• Exercises by walking 2–3 times per week
Review of Systems (ROS)
General: Fatigue, no fever or weight loss
