, Patient Information
Name: Regina Ricardo
Age: 66 years old
Gender: Female
Height: 5’2” (assumed for BMI calculation, based on average for
Hispanic-American females)
Weight: 160 lbs (assumed, BMI ~29.3 kg/m², overweight)
Reason for Encounter: Trouble sleeping
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. She describes difficulty falling asleep (sleep-onset
insomnia), taking 1–2 hours to fall asleep, and frequent nighttime
awakenings (sleep-maintenance insomnia), resulting in only 4–5 hours
of sleep per night. She reports feeling fatigued during the day, with
difficulty concentrating and irritability, impacting her daily activities.