Patient’s Description:
Ms. Jones came to the clinic today because she’s been having trouble sleeping for about a month. She says her sleep is not deep and she wakes up feeling tired. She also mentions experiencing xx difficulty. Normally, she sleeps around 4 or 5 hours each night and wakes up at 8:00 am every day. Her weekday and weekend schedules are pretty consistent. She doesn’t use any sleep aids, prescription or over-the-counter. Before bedtime, she avoids screens and stops drinking caffeine by 4 pm every day. She’s been feeling xxx lately. She doesn’t have trouble waking up, but she feels tired in the morning and has fatigue during the day (she rates it as a 5 out of 10 in terms of severity), along with restlessness and irritability (which she rates as 2 out of 10 in terms of severity). She hasn’t been taking xxx.
About Her Life:
She’s feeling stressed about her upcoming exams and job search after graduation. But she says she has a good support system of friends and family, and she’s active in her church. To cope with stress, she stays organized and enjoys reading and watching TV for 1-2 hours a day. She also xxx. She doesn’t smoke, but she drinks about 10-12 alcoholic drinks a month, never more than 3 at a time, and she doesn’t think it affects her sleep. She used marijuana before, but not currently, and she doesn’t use any other drugs. She doesn’t xxx, but she xxx every day. She drinks 1-3 diet colas daily. Her family doesn’t have a history of known sleep or psychiatric issues.
Health Check:
• Overall: No changes in weight, weakness, fever, chills, or night sweats. However, she complains of xxx.
• Nervous System: No numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures. But she has noticed changes in concentration and sleep. No problems with coordination.
• Mental Health: She feels like her mood is off and she’s more anxious due to exams and job search. She hasn’t been diagnosed with depression, but she feels helpless and notices a decline in her performance at work and school. She denies tension or memory loss. She hasn’t attempted suicide in the past and denies thoughts of harming herself or others.
Assessment:
Ms. Jones is experiencing sleep problems due to anxiety.
Treatment Plan:
• Encourage Ms. Jones to keep track of her insomnia and anxiety symptoms, including what triggers them, and bring the record to her next visit.
• Advise her to cut down on caffeine and increase water intake.
• Provide education on xxx. Continue with xxx.
• Talk about the importance of maintaining a regular sleep schedule and good sleep habits, such as avoiding caffeine after 2 pm, limiting fluids after dinner, reducing screen time before bed, and getting out of bed if she can’t sleep.
• Educate her about xxxand medications that might help (like diphenhydramine and Tylenol PM).
• Teach her when to seek further help, especially if she feels hopeless or has thoughts of self-harm.
• Schedule a follow-up appointment in 2-4 weeks to check on her progress.
Shadow Health Tina Jones Mental Health Documentation
Subjective
HPI: Ms. Jones presents to the clinic complaining of difficulty sleeping which she notes to have started 1 month ago. She states that her sleep is “shallow and not restful”. She complains of xx difficulty. On average she sleeps 4 or 5 hours per night and awakens at 8:00am daily. She states that she has a fairly consistent schedule on weekdays and weekends. She does not take any prescription or over the counter sleep aids. She limits screen time prior to bed and does not ingest caffeine after 4pm daily. She endorses xxxover the past month. She denies difficulties awaking, but does not feel rested in the morning and has daytime fatigue (rates 5/10 severity), restlessness, and irritability (rates 2/10 severity). She does not take xxx.
Social History: She states that she has some stress related to her upcoming examinations and her impending job search upon graduation. She states that she has a strong support system made up of friends and family and she is active in her church. She states that she copes with stress by staying organized. She enjoys reading and watching television (1-2 hours per day). She states that xxxas well. She denies use of tobacco. She drinks approximately 10-12 alcoholic beverages per month, but never more than 3 per sitting and does not note any impact on her sleep. She has used marijuana in the past, but no current use and denies other illicit drugs. She does not xxx, but states that xxx daily. She drinks 1-3 diet colas per day. Family History: Denies any history of known sleep disorders or psychiatric disorders.
Review of Systems:
• General: Denies changes in weight, weakness, fever, chills, and night sweats. Does complain ofxxx.
• Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures. Endorses changes in concentration and sleep. Denies changes or difficulties in coordination.
• Psychiatric: States that her mood has been “off” and she does not feel like herself. She does complain of increased anxiety related to upcoming exams and job search. She has no history of depression, but does state that she feels helpless and notes that her performance at work and school is beginning to decline. She denies tension or memory loss. No past suicide attempts. Denies suicidal or homicidal ideation.
Assessment
Sleep disturbance related to anxiety
Plan
• Encourage Ms. Jones to continue to monitor symptoms and log her episodes of insomnia and anxiety with associated factors and bring log to next visit.
• Encourage to decrease caffeine consumption and increase intake of water and other fluids.
• Educate on xxx. Continue to xxx.
• Discuss need to maintain regular sleep and wake schedule and sleep hygiene techniques including limiting caffeine after 2pm, limiting fluids after dinner, limiting screen time or stimulating activities after 8pm, and to get out of bed if awaken in the middle of the night.
• Educate toxxxand depressant medications (including diphenhydramine and Tylenol PM).
• Educate on when to seek further or emergent care including feelings of self-harm or hopelessness.
• Revisit clinic in 2-4 weeks for follow-up and evaluation.
