HISTORY:
Insomnia for
Type:
Awakenenings: times during the night, taking to fall back asleep
Total sleep time: hours per night
Impact on daily activities:
Treatments tried: ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , speech , mood , thought process , , judgment
ASSESSMENT:
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
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- Referral to psychologist
- Referral to sleep specialist
- Follow-up in
- Return if insomnia worsens or if new symptoms develop such as mood disturbances