,
,Patient Information
Name: Regina Ricardo
Age: 66 years old
Gender: Female
Height: 5’2” (157 cm, based on average for Hispanic-American
females)
Weight: 160 lbs (72.6 kg, BMI ~29.3 kg/m², overweight)
Reason for Encounter: Trouble sleeping for 3 months
Setting: Primary care clinic
Class: 6512, Week #4
History of Present Illness (HPI)
Regina Ricardo, a 66-year-old Hispanic-American female, presents to
the primary care clinic with a chief complaint of trouble sleeping for the
past 3 months, characterized by difficulty initiating sleep (sleep-onset
insomnia, taking 1–2 hours to fall asleep) and frequent nighttime
awakenings (sleep-maintenance insomnia, 3–4 awakenings per night),
resulting in 4–5 hours of total sleep. She reports daytime fatigue,
irritability, and difficulty concentrating, which impair her ability to
, manage household tasks and enjoy social activities. Regina attributes
her sleep difficulties to stress and anxiety following the death of her
husband 6 months ago, which has led to grief, loneliness, and financial
concerns as she navigates life as a widow. She denies snoring,
witnessed apneas, leg twitching, or nocturnal discomfort, reducing
suspicion for obstructive sleep apnea (OSA) or restless leg syndrome
(RLS). She reports occasional sadness but denies core depressive
symptoms (e.g., anhedonia, hopelessness, suicidal ideation).Regina
consumes 2–3 cups of coffee daily (last cup 3 PM, ~200–300 mg
caffeine), which may delay sleep onset, and a glass of wine nightly (7
drinks/week) to “relax,” which may fragment sleep. Her sleep schedule
is irregular, with bedtimes varying between 10 PM and 1 AM and wake
times between 6 AM and 8 AM, often staying awake worrying about
finances or family. She denies excessive screen time before bed but
occasionally watches TV late at night. Regina rates her sleep quality as
poor (3/10) and her daytime energy as low (4/10), significantly affecting
her quality of life.
Onset: Insidious, starting 3 months ago, temporally linked to
increased stress post-husband’s death.
Location: N/A (systemic sleep complaint).
Duration: Chronic (>3 months), occurring 5–6 nights/week.
,Patient Information
Name: Regina Ricardo
Age: 66 years old
Gender: Female
Height: 5’2” (157 cm, based on average for Hispanic-American
females)
Weight: 160 lbs (72.6 kg, BMI ~29.3 kg/m², overweight)
Reason for Encounter: Trouble sleeping for 3 months
Setting: Primary care clinic
Class: 6512, Week #4
History of Present Illness (HPI)
Regina Ricardo, a 66-year-old Hispanic-American female, presents to
the primary care clinic with a chief complaint of trouble sleeping for the
past 3 months, characterized by difficulty initiating sleep (sleep-onset
insomnia, taking 1–2 hours to fall asleep) and frequent nighttime
awakenings (sleep-maintenance insomnia, 3–4 awakenings per night),
resulting in 4–5 hours of total sleep. She reports daytime fatigue,
irritability, and difficulty concentrating, which impair her ability to
, manage household tasks and enjoy social activities. Regina attributes
her sleep difficulties to stress and anxiety following the death of her
husband 6 months ago, which has led to grief, loneliness, and financial
concerns as she navigates life as a widow. She denies snoring,
witnessed apneas, leg twitching, or nocturnal discomfort, reducing
suspicion for obstructive sleep apnea (OSA) or restless leg syndrome
(RLS). She reports occasional sadness but denies core depressive
symptoms (e.g., anhedonia, hopelessness, suicidal ideation).Regina
consumes 2–3 cups of coffee daily (last cup 3 PM, ~200–300 mg
caffeine), which may delay sleep onset, and a glass of wine nightly (7
drinks/week) to “relax,” which may fragment sleep. Her sleep schedule
is irregular, with bedtimes varying between 10 PM and 1 AM and wake
times between 6 AM and 8 AM, often staying awake worrying about
finances or family. She denies excessive screen time before bed but
occasionally watches TV late at night. Regina rates her sleep quality as
poor (3/10) and her daytime energy as low (4/10), significantly affecting
her quality of life.
Onset: Insidious, starting 3 months ago, temporally linked to
increased stress post-husband’s death.
Location: N/A (systemic sleep complaint).
Duration: Chronic (>3 months), occurring 5–6 nights/week.
