Insomnia

HISTORY:

Insomnia for ‍ ‍hoursdays

Type: ‍difficulty falling asleepdifficulty staying asleepwaking up too early

Awakenenings: ‍ times during the night, taking ‍ ‍minhours to fall back asleep

Total sleep time: ‍ hours per night

Impact on daily activities: ‍minimal

Treatments tried: ‍none, ‍effectiveineffective

‍fatigue

‍daytime sleepiness

‍depressed mood

‍anxiety

‍irritability

‍difficulty concentrating

‍memory problems



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Neurologic: cranial nerves ‍normal, strength ‍5/5 throughout, sensation ‍normal, reflexes ‍2+ throughout, cerebellar function ‍normal, gait ‍stable

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought process ‍organized, ‍no suicidal ideation, judgment ‍good



ASSESSMENT:

‍Insomnie ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Sleep diary

- Sleep study

- Good sleep hygiene: maintain a consistent sleep schedule of 7-8 hours, dim lights and avoid screens before bedtime, ensure a dark and cool sleep environment, and refrain from taking a naps

- Avoidance of caffeine, drugs, stimulants, and alcohol

- Cognitive behavioral therapy

- ‍Sleep medications

- ‍Antidepressants

- ‍Benzodiazepines

- ‍Antihistamines

- Referral to psychologist

- Referral to sleep specialist

- Follow-up in ‍ ‍weeksmonths

- Return if insomnia worsens or if new symptoms develop such as mood disturbances