Insomnia Case Study

• Lai Pui Yan

Case

*To protect volunteer privacy, report will not show the pictures of face, breast ,thoracic etc.

15/3/2015 2:00pm

Mrs. Hung , age 44 years old, divorced mother being a nurse in Hong Kong. Hung lives with a 20 years old gaughter.

Source and Reliability. Self-referred; seems reliable

Chief Complaint:“ I awoke suddenly from sleep at midnight for a long time.”

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Present Illness:

Present Illness: For about 2-3 years, Mrs. Hung has had increasing problems with sleeping. Because of her job (nurse), Hung has to wake up at 5am, sometimes 9am, even stay up all night. Also Hung needs to work one more part time to cope with financial pressure that bringing up her children. Now She awoke suddenly from sleep at midnight,Sleeps on average for 5 hours per night. And usually Awakened 2-3 times at 1-4am, also cannot fall asleep again. She had asking support from traditional chinese physician and western medicine. She eats three meals a day and only drinks warm water.

• Medications

Taking different hypnagogue, such as diazepam. 1 to 2 tablets before sleeping as needed.

Hormone medicine to regulate the biological clock.Long-term medication.

• Past History

• Childhood Illnesses: fever, common cold.
• Adult Illnesses.

• Medical:None.
• Surgical: Ob/Gyn, with normal vaginal deliveries.one living children. Menarche age 12. Last menses 20 days ago. No interest in sex, and not sexually active.
• Psychiatric: None.
• Health Maintenance

• Immunizations: Immunizations: Varicella vaccination & tetanus shots × 2, (unknown year) followed with booster 1 year later.
• Screening tests: None.

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Family History

Father ,80, with headaches and little mild arthritis problem, have smoking habits. Mother, 77, have liver cancer.

Two brother, 42&40, one have smoking habits. Overall is well.

One sister, 45, overall is well.

Two Nephew, 9&10, one have appendicitis once time. Overall is well.

Two Niece , both 16. Overall is well.

No family history of diabetes, tuberculosis, heart or kidney disease, anemia, epilepsy, or mental illness.

• Personal and Social History: Born and raised in Hunan , finished high school and nursing school. Worked as nurse for 26 years, the19 years old moved to Hong Kong and married at age 20, had 1 daughter. 17 years ago Hung divorced with her husband. She has lots of friends. Have church support and be baptized.

She works irregularly, sometimes wake up at 5:00 a.m , or stay up all night.

• Exercise and diet: Gets little exercise. Diet high in seafood and vegetables.
• Safety measures: Medications kept in an unlocked medicine cabinet. Not using seat belt regularly. Cleaning solutions are below the sink.

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Physical examination and findings:

• General appearance
  • Mrs. Hung is well-groomed, and kind woman. She has black eye, seems tired.

• Vital signs
  • Ht (without shoes) 153 cm . Wt (dressed) 47 kg (102 lb). BMI 20. BP 112/72 right arm, supine; 108/66,left arm, supine. Heart rate (HR) 70 and regular. Respiratory rate (RR) 14.Temperature (oral) 98.6°F.

• Skin
  • Color pink. Skin warm and moist. Nails without clubbing or cyanosis. No suspicious, nevi. No rash, petechiae, or ecchymoses.

• Head, Eye and ENT
  • Head, Eyes, Ears, Nose, Throat (HEENT). Head: Hair of average texture, but uneven distribution.Scalp without lesions, normocephalic/atraumatic (NC/AT).

• Eyes: Vision 20/20 in each eye. Visual fields full by confrontation. Conjunctiva pink; sclera white. Pupils 4 mm constricting to 2 mm, round, regular, equally reactive to light. Extraocular movements intact. Disc margins sharp, without hemorrhages, exudates. No arteriolar narrowing.

• Ears: Wax partially obscures right tympanic membrane (TM); left canal clear, TM with good cone of light. Acuity good to whispered voice. Weber midline. AC > BC. Wearing earrings.

• Nose:Mucosa pink, septum midline. No sinus tenderness.
• Mouth: Oral mucosa pink. Have decayed tooth. Tongue midline. Tonsils absent. Pharynx without exudates.

• Neck
  • Neck supple. Trachea midline. Thyroid isthmus palpable, lobes not felt.

• Breast
  • Breasts symmetric and smooth without masses. Nipples without discharge.

• Thoracic and Lungs
  • Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no rales, wheezes, or rhonchi. Diaphragms descend 4.2 cm bilaterally.

• Cardiovascular and peripheral circulation
  • The jugular venous pulse (JVP) is 4 cm above the sternal angle with the head of bed elevated to 30 degrees. Carotid upstrokes are brisk, without bruits. The point of maximal impulse (PMI) is tapping, 7 cm lateral to the midsternal line in the 5th intercostal space. Crisp S1 and S2. At the base, S2 is greater than S1 and physiologically split, with A2 > P2. At the apex, S1 is greater than S2 and constant.

• No murmurs or extra sounds.

• Abdomen
  • Bowel sounds active. It is soft and nontender; no palpable masses or hepatosplenomegaly. Liver span is 6.5 cm in the right midclavicular line; edge is smooth. Spleen and kidneys not felt. No costovertebral angle (CVA) tenderness.

• Musculoskeletal system
  • No joint deformities. Have good movement. Good range of motion in hands,wrists, elbows, shoulders, spine, hips, knees, ankles..

• Neural system

• Mental Status:Alert, tense, and cooperative.Look tired. Thought process loose.Oriented to person, place, and time.
• Cranial Nerves: II–XII intact.
• Motor: Good muscle bulk and tone. Strength 5/5 throughout.
• Cerebellar:Rapid alternating movements (RAMs), point-to-point movements intact. Gait with normal base.
• Sensory: Pinprick, light touch, position sense, vibration, and stereognosis

intact. Romberg—maintains balance with eyes closed. No pronator drift.

• Lymph nodes

• Small (<1 cm), soft, nontender. No axillary or epitrochlear nodes.

Review on 12 activities of living

Assessment and Plan

1. Sleeping quality: Even Hung had asking support from traditional chinese physician and western medicine, taking different hypnagogue and hormone medicine, The quality of sleep is still bad. May be related to shift work and pressure. The financial pressure that bringing up her children, working too much that cannot have a enough rest.

Plan:

Cope with shift work:

• Decrease the number of night or irregular shifts, if Hung can change the shifts with colleague.
• Avoid rotating shifts. if Hung needs to work at 5am to 3pm, then maintain the same sleep schedule, avoiding wake up 9am next day.
• Use blackout curtains, turn off the phone and stay far away from Hung, reject the noise and light from bedroom.

Cope with psychological problem(stress):

• Before 1 hour, do not think what need to do at the bed time.
• Hung can chat with her friends, and share the pressure to solve the problem.
• Asking support to Psychiatrist

• Also, don’t take too much drugs to helping sleep.

2. High diet of seafood: In favour of seafood, 2-3 days have once in the meals. A healthy meal should not be too much protein. Also, eating too much seafood will cause the high rate of cholesterol.

Plan:

• Decrease the meal of seafood, changing to 1-2 meals of seafood in a week.
• Replace the seafood that some food texture and flavor are similar to seafood, like Soybean products.