iHuman Case Study: 65-Year-Old Female Patient
Presenting with Trouble Sleeping (Class 6531) - Week
#9
,
,
, Chief Complaint and Reason for Encounter
Patient Information:
o Age: 65 years
o Gender: Female
Reason for Encounter:
o The patient is presenting to the outpatient clinic due to ongoing trouble sleeping.
She reports difficulty falling and staying asleep, which has been impacting her
daily activities and quality of life.
Chief Complaint:
o Primary Concern: Trouble sleeping for the past several months.
o Associated Symptoms:
Waking up frequently during the night.
Feeling tired and unrefreshed after waking up.
Increased irritability and mood swings due to lack of sleep.
History of Treatment:
o The patient has tried over-the-counter sleep aids with minimal relief.
o Reports no improvement in sleep quality despite attempting lifestyle changes such
as reducing caffeine and establishing a nighttime routine.
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