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Sleep awake disorders
Criteria Clinical Notes Subjective Patient information: Susan 45 - year-old Caucasian female. Include chief CC :^ “I’ve^ been^ having^ trouble^ sleeping” complaint, subjective HPI : information from the Susan is a 45 - year-old Caucasian female who visited the clinic with patient, names and complaints of sleep disturbances for last three months. She recently relations of others underwent a hysterectomy due to uterine fibroids. Her OBGYN present in the physician, Dr. Ferris, prescribed hormone replace therapy (HRT) but interview, and basic patient, after doing some of her own research, decided to demographic discontinue treatment because of concerns about potential cancer information of the risks, especially due to her mother’s history of cancer. After her patient. HPI, Past decision to stop HRT, Susan had experienced sleeping disturbances Medical and such as tossing and turning, inability to achieve deep sleep, and Psychiatric History, sleeping only 2 - 3 hours per night. She reported feeling anxious and Social History. desperate to sleep, and increase in stress levels due to her inability to focus during the day on her work. Susan reported that her job performance is negatively impacted by her lack of sleep, and also social interactions with her friends. She stated that she needs to take naps during the day whenever possible, and that disrupts her daily life and schedule. Also, reported that over-the-counter sleep aids are not helping much. Past Psychiatric History General statement: Denies history of mental illness. Caregiver: none Hospitalizations: none Allergies: NKDA Medications: D.C. does not currently take any medication. Was prescribed HRT but does not take anymore. Pychotherapy or prior psychiatric diagnosis: Denies. Substance abuse history : patient denies taking any drugs or smoking, or drinking alcohol. Family Psychiatric history : Mother was diagnosed with GAD after her cancer diagnosis. Denies any suicides, or any other known psychiatric conditions in the family. Social history : Susan is a freelance writer for a local paper. She is married to Mark and live in Seattle. She had friends and a social life but since her sleep problems, she avoids going out and cancels a lot of her plans to accommodate her need for sleep such as taking naps during the day. Medical History : History of benign uterine fibroids, recent
hysterectomy. ROS General: Denies chills, fatigue, or recent weight changes. HEENT: Head – denies headaches, or lightheadness, or trauma. Eye – denies blurry vision, or photophobia or pain. Ear – denies pain or discharge, or hearing loss. Nose and Throat: denies any pain/soreness or other issues. Skin: denies jaundice, itchiness, or rashes. Cardiovascular: Reports palpitations, chest thightness, and shortness of breath. Denies any edema, or heart murmurs. Respiratory: Denies cough, wheezing, or dyspnea. GI: Denies N/V/D/C. Denies acid reflux. Neurological: Denies numbness, tingling, headaches, dizziness, or syncope. Objective ROS: see above Objective data Vital Signs BP: 121/76 HR: 76 RR: 18 SPO2: 97% T: 98. Pain: 0/ Height: 5’5 Weight: 130 BMI: 21.6 normal Diagnostic results : GAD- 7 : score 10, which indicates moderate anxiety Thyroid function test, CBC, CMP, Troponin: Normal Toxicology screening: negative BAC level: normal ECG: Normal Mental status examination He is a 45-year-old Caucasian female who is in dressed appropriately, has a clean appearance, and seems her stated age. She appeared hesitant at first but starts cooperating during the interview. Appeared anxious, and restless but speech was clear, coherent, and of a normal volume and tone. Affect is congruent with mood when discussing her sleep issues. Susan had a logical thought process, and made clear connections between her inability to sleep, fears and worries regarding her family history of cancer. Her judgment is compromised because of her fears and health concerns, evidenced by her stopping HRT despite Dr. Ferris’ recommendations. Susan denied delusions, visual or auditory hallucinations, or suicidal thoughts. She is alert and oriented x4, and in control of this thoughts and actions. Cognitive function might be impaired due to fatigue. She has intact memory, and her understanding of her situation is average. This is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” Include MSE, risk assessment here, and psychiatric screening measure results. Assessment Diagnosis
- Once stressor is terminated, the symptoms do not persist more than 6 months. Susan’s recent hysterectomy brought a lot of concerns about her health, especially given her family history of cancer. The stress related to her surgery, HRT and the changes in her health status are identifiable stressors that lead to anxiety. Her anxiety symptoms have caused distress and impairment, affecting her daily functionin (e.g., her struggles to focus on her freelance writing, the quality of her work, and her social interactions). She felt overwhelmed and fearful about losing her job due to her inability to perform. Plan Treatment plan
- For both Insomnia Disorder and Adjustment Disorder, evidence-based psychotherapeutic approaches are essential. Medication can be a part of the treatment plan but should be considered carefully and typically for a limited duration, especially for insomnia.
- First line of treatment is Cognitive Behavioral Therapy.
- Sleep Hygiene: a regular sleep schedule, a restful environment, avoid caffeine or heavy meals before bedtime, and limiting screen time or exercise in the evening.
- Medication: Non-benzodiazepines : Such as zolpidem or eszopiclone, which can help initiate and maintain sleep. Melatonin Receptor Agonists : Such as Ramelteon, which can help regulate the sleep-wake cycle. Antidepressants like trazodone or doxepin, can help with sleep while addressing underlying anxiety.
- Mindfulness reduction therapy and physical activity can reduce symptoms of anxiety (Locke et.al.,2015).
- Identifying and eliminating potential triggers (such as caffeine, dietary triggers, stress), as well as increasing physical activity and sleep quality and quantity, are common lifestyle advice that may lessen anxiety-related symptoms.
- Follow up with D.C. in 2 weeks to evaluate the side effects, and effectiveness of the treatment plan. Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment.
References: American Psychiatric Association. (2022). Diagnostic and statistical Manual of Mental Disorders, text revision (5th ed.). American Psychiatric Association. Carlat, D. (2017). The psychiatric interview (4th ed.). Philadelphia Wolters Kluwer. Gottschalk, M. G., & Domschke, K. (2017). Genetics of generalized anxiety disorder and related traits. Dialogues in clinical neuroscience , 19 (2), 159–168. https://doi.org/10.31887/DCNS.2017.19.2/kdomschke
