Health Assessment

Trouble Sleeping

Carnel C. Jackson, DNP, RN, FNP-BC

Case Study

Chief Complaint

“I have not been sleeping; I am up all of the hours of the night.”

Patient Profile

Name: Ivan Khrodosh

Age: 34

Gender: male

History of Presenting Illness

I.K. is a 34-year-old man and retired Marine veteran who presents complaints of chronic insomnia, which has been progressively worsening over the past few months.* He reports difficulty initiating sleep, often lying awake for hours, and frequent nighttime awakenings associated with vivid night terrors.* He is able to fall asleep when he drinks alcohol. Ivan admits to drinking 2-3 beers nightly in an attempt to help himself relax and fall asleep.* However, he reported alcohol initially makes him drowsy and is effective for a few hours and then he wakes up.* These night terrors are described as intense and sometimes accompanied by physical movements and shouting.*

He has a known history of post-traumatic stress disorder (PTSD) related to his military service, which he associates with his night terrors and hypervigilance at night.* He denies current suicidal ideation, but reports a past suicide attempt 3 years ago.* He has no significant medical conditions aside from PTSD, which he uses prazosin for.

Medical History

Gastroesophageal reflux disease, post traumatic stress disorder, night terrors

Medications

Omeprazole: 20 mg by mouth daily

Prazosin: 1 mg by mouth nightly

Social History

  • Accountant
  • Marine vet; honorable discharge
  • Lives in a two-story home with his wife and dog.
  • Alcohol use: 2 or 3 beers (12 oz) nightly
  • Tobacco smoke: none
  • Illicit drug use: prior marijuana use, none in the last 5 years

Family History

Adopted: Not in touch with biological family

Review of Systems

  • Constitutional: Denies chills, fever. Tired.
  • HEENT: Denies postnasal drip, sore throat, hearing impairment. Denies blurred vision.
  • Respiratory: Denies shortness of breath, cough, wheezing.
  • Cardiovascular: Denies chest pain and pedal edema.
  • Gastrointestinal: Denies abdominal pain, tenderness, nausea and emesis. Denies constipation, diarrhea, hematochezia. Denies appetite changes and melena.*
  • Derm: Denies breaks in the skin, lesions, and rashes.
  • Neurological: Denies headaches, tremors, and dizziness.
  • Hematologic: Denies easy bruising.
  • Psychiatric: Endorses insomnia, denies hallucinations, denies suicidal/homicidal ideation.

Physical Assessment

Vitals

  • Blood pressure: 130/80 mm Hg
  • Heart rate: 66 bpm
  • Respiratory rare: 16 bpm
  • Temperature: 97.6℉
  • Oxygen saturation: 99% on room air

General Survey

  • General appearance: Alert, oriented, slender male, disheveled appearance.
  • HEENT: Moist mucous membranes, PERRLA, thyroid exam normal, tonsils grade 1.
  • Cardiovascular: Normal rhythm without murmurs, normal s1 and s2.
  • Respirations: Clear to auscultation bilaterally.
  • Abdomen: Active bowel sounds x4, nontender on palpation, nondistended.
  • Derm: Without abrasion or ulceration; without rash.
  • Neurological: No focal deficits, no signs of confusion or cognitive impairment. Positive monofilament.
  • Psychiatric: Speech with normal rate and tone, unpressured, no dysarthria, no hallucinations.*
  • Extremities: No asterixis with extension of hands

Diagnostic Tool(s)

  • PHQ9-6, no suicidal ideation
  • GAD7- 4

Assessment

Most likely diagnosis:

  • Insomnia r/t to PTSD
  • Mild depression

Treatment Plan

  1. Discuss medication options
  2. Recommend mental health therapy
  3. Address and discuss suicide/homicide hotline

Review Questions

Click the arrow to expand the section and view the correct answers.

  1. Which of the following is a hallmark symptom of PTSD?
    1. Persistent feelings of sadness
    2. Flashbacks and intrusive thoughts
    3. Increased appetite and weight gain
    4. Frequent headaches without cause
Answer:

Flashbacks and intrusive thoughts. PTSD is characterized by intrusive symptoms, such as distressing memories, nightmares, or flashbacks related to a traumatic event.

  1. What is the most common cause of chronic insomnia?
    1. Medications
    2. Stress and psychiatric disorders
    3. Chronic pain
    4. Substance abuse
Answer:

Stress and psychiatric disorders. Chronic stress, anxiety, depression, and PTSD are leading contributors to persistent insomnia.

  1. A hallmark symptom of insomnia disorder is:
    1. Sleeping more than 10 hours per night
    2. Difficulty initiating or maintaining sleep despite opportunity
    3. Increased sleep efficiency
    4. Hypersomnia during the day without nighttime sleep problems
Answer:

Answer: Difficulty initiating or maintaining sleep despite opportunity

Feedback: Insomnia is defined by difficulty falling or staying asleep, early morning awakenings, or non-restorative sleep despite adequate opportunity.

  1. Which sleep disorder is most associated with PTSD?
    1. Narcolepsy
    2. Sleep apnea
    3. Nightmares and insomnia
    4. Restless legs syndrome
Answer:

Nightmares and insomnia. PTSD frequently causes nightmares, hyperarousal, and difficulty sleeping due to persistent fear responses.

  1. Which lifestyle modification is most effective for improving sleep in patients with insomnia?
    1. Napping during the day
    2. Avoiding exercise in the morning
    3. Maintaining a consistent sleep schedule
    4. Using electronic devices before bed
Answer:

Maintaining a consistent sleep schedule. Sleep hygiene strategies, such as maintaining a regular sleep schedule, help regulate circadian rhythms and improve insomnia.

  1. Which of the following are common risk factors for PTSD? (Select all that apply).
    1. Military combat exposure
    2. Childhood abuse or neglect
    3. Traumatic brain injury
    4. Excessive caffeine intake
    5. Sexual assault
Answer:

Answers: Military combat exposure, childhood abuse or neglect, traumatic brain injury, sexual assault.

Feedback: PTSD is triggered by exposure to traumatic events, including military combat, abuse, brain injuries, and assault.

  1. Which of the following best explains how alcohol affects the sleep pattern?
    1. Alcohol use increases REM sleep and improves sleep quality
    2. Alcohol use increases ability to initiate sleep, but disrupts sleep quality later in the night
    3. Alcohol has not significant effect on sleep stages
    4. Alcohol use consistently helps prevent sleep disturbance
Answer:

Alcohol use increases the ability to initiate sleep, but disrupts sleep quality later in the night. Alcohol use increases ability to initiate sleep, but disrupts sleep quality later in the night.

  1. Mr. Khrodosh reports drinking before bed to help him calm down. As part of the health assessment, which screening tool is most appropriate to evaluate his alcohol use?
    1. PHQ-9
    2. AUDIT-C
    3. Epworth Sleepiness Scale
    4. Insomnia Severity Index
Answer:

AUDIT-C. The AUDIT-C is a validated screening tool to assess risky alcohol consumption. PHQ-9 screens for depression, Epworth Sleepiness Scale assesses daytime sleepiness, and the Insomnia Severity Index evaluates insomnia severity.

Clinical Pearls

* All areas with asterisks are highlighted for a patient with this chief complaint.

  • Insomnia and Alcohol Use with PTSD
  • Common across the age spectrum
  • Alcohol is a CNS depressant and promotes sleep onset
  • Alcohol will cause decreased sleep quality and fragmented sleep
  • Psychiatric diagnoses focus more on questioning than physical exam, but both play key roles in proper diagnosis and treatment.

Ask:

  • Quality of sleep, quantity, bedtime routines, environment, caffeine or sedative use, excessive daytime fatigue, observed apneic events

Red flags:

  • Tolerance, morning alcohol use and/or inability to stop drinking
  • Tremors or sweats

Screen:

  • Always screen for co-existing mental health conditions, such as anxiety and depression

Treatment:

  • Cognitive behavioral therapy
  • Counseling/support groups for alcohol misuse
  • Be cautious with pharmacologic therapy
  • Benzodiazepines pose the risk of addiction and respiratory depression
  • Preferred options: trazodone, gabapentin, melatonin or ramelteon

Expect improvement after 4-12 weeks of alcohol abstinence

References

OpenAI. (2024). ChatGPT (June 7 version) [Large language model]. https://chat.openai.com/chat

Winkelman, J. W. (2025). Overview of the treatment of insomnia in adults. In R. Benca (Ed.), UpToDate. https://www.uptodate.com/contents/overview-of-the-treatment-of-insomnia-in-adults

definition

License

Icon for the Creative Commons Attribution-NonCommercial 4.0 International License

Be Prepared for Your Nurse Practitioner Clinical Readiness Exam Copyright © 2026 by Elizabeth Heavey, Renee Biedlingmaier, Colleen Burgoyne and Carnel C. Jackson is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

Share This Book