Insomnia

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of insomnia

Described as ‍difficulty falling asleepdifficulty staying asleepwaking up too early

Awakens ‍ times during the night, takes ‍ ‍minhours to fall back asleep

Total sleep time ‍ hours per night, ‍feelsdoesn't feel refreshed on waking

Impact on daily activities: ‍minimal

Alleviating factors: ‍none, ‍effectiveineffective



Associated symptoms: *Try using right-click for negatives*

‍fatigue

‍daytime sleepiness

‍depressed mood

‍anxiety

‍irritability

‍difficulty concentrating

‍memory problems



Contributing factors:

‍stress

‍high caffeine intake

‍alcohol

‍shift work

‍frequent travel

‍heavy meals before bedtime

‍lack of physical activity

‍use of electronic devices before bed

no history of: ‍depression, ‍anxiety, ‍chronic pain, ‍restless leg syndrome, ‍sleep apnea, ‍head injury

no use of: ‍stimulants, ‍new medication





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

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

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍

Neurologic: cranial nerves ‍intact, strength ‍intact 5/5, sensation ‍intact, reflexes ‍intact 2+, cerebellar function ‍intact, gait ‍steady

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought ‍organized, ‍suicidal ideation, judgment ‍good





ASSESSMENT:

‍Insomnie ‍likelysuspectedpossible

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

- ‍Sleep medications

- ‍Antidepressants

- ‍Benzodiazepines

- ‍Antihistamines

Further care:

- Referral to psychologist

- Referral to sleep specialist

- Follow-up in ‍ ‍weeksmonths

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