Difficulty Sleeping
Age: years old
Gender:
HISTORY:
Presents with a - history of insomnia
Described as
Awakens times during the night, takes to fall back asleep
Total sleep time hours per night, refreshed on waking
Impact on daily activities:
Alleviating factors: ,
Associated symptoms: *Try using right-click for negatives*
Contributing factors:
no history of: , , , , ,
no use of: ,
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , speech , mood , thought , , judgment
ASSESSMENT:
DDx: primary insomnia, poor sleep hygiene, psychophysiological insomnia, paradoxical insomnia, idiopathic insomnia, sleep apnea, restless legs syndrome, periodic limb movement disorder, circadian rhythm sleep-wake disorders, adjustment disorder, depression, anxiety disorders, substance abuse, medication side effects, chronic pain syndromes, neurological disorders, hyperthyroidism, GERD, heart failure, nocturia, menopause, pregnancy
PLAN:
Investigations:
- Sleep diary
- Sleep study
Treatments:
- 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
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Further care:
- Referral to psychologist
- Referral to sleep specialist
- Follow-up in
- Return if insomnia worsens or if new symptoms develop such as mood disturbances
HISTORY: Associated symptoms: EXAM: ASSESSMENT: PLAN: