Advanced Physical Assessment

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 difficulty falling asleep at least 4 or 5 nights per week, but states that she is able to stay asleep without difficulty. On average she sleeps 4 or 5 hours per night and awakens at 8:00 am 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 4 pm daily. She endorses decreased feelings of sleepiness over the past month. She denies difficulties waking, 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 naps. 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 her father died in a car accident a year and a half ago, which was difficult for her and she experienced some difficulties with sleep at that time as well. She denies the 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 exercise regularly but states that her job is somewhat active and she walks 5-15 minutes 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 of increasing daytime fatigue. 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 searches. 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 stress

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 the next visit. Encourage to decrease caffeine consumption and increase intake of water and other fluids. Educate on anxiety reduction strategies including deep breathing, relaxation, and guided imagery. Continue to monitor and explore the need for possible referral to social work/psychiatry or pharmacologic intervention. Discuss need to maintain regular sleep and wake schedule and sleep hygiene techniques including limiting caffeine after 2 pm, 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 to limit alcohol and 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.