iHuman Week 4 - Jennifer Alberson, 65 year old female - CC:trouble sleeping

Amber Waddell

Subjective Jennifer Alberson

Chief complaint: trouble sleeping

History of present Illness:

 Patient is a 65 year old female. Patient presents with complaints of trouble sleeping. Stared a couple

months ago and was intermittent. Now it is multiple times a week. Patient has problems both falling

asleep and staying asleep. Patient tosses and turns for 1-2 hours trying to go to sleep then wakes up at 2-

3AM and has trouble going back to sleep. Patient is a light sleeper and awakes with noise.

Review of system:

Constitutional: Patient reports feelings of nerviousness. Denies depression, anxiety. Increase in

weight loss. Denies fevers

Head/ neck: she has occasional headaches. Denies a decrease in ROM in the neck. Denies

vertigo or dizziness. Denies any pain in the neck.

EENT: denies sinus pain or pressure. Positive for nasal congestion and runny nose. Denies ear

pain or pressure. Negative for tongue or lip swelling. Able to handle oral secretions. Denies changes in

vision. Denies double vision or blurriness.

Cardiac: palpitations,

Respiratory: denies chest pain or pressure. Denies chest tightness

GI: Has feelings of heart burn. Has frequient bowel movements. Denies abdominal pain, nausea

or vomiting.

Heme/ Lymph: Denies swollen lymph nodes or bruising.

Skin: denies skin color changes, rashes, or open wounds. Patient states hair is thinning

Muscular: denies change in gait. Denies pain in arms and forearms. denies muscle weakness of

the legs or feet. Denies pain of the legs or feet, denies stiffness.

Medical history: none

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iHuman Week 4 - Jennifer Alberson, 65 year old female - CC:trouble sleeping