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
Version | 2022 |
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Pages | 4 |
Language | English |
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