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
This is where the Objective data
“facts” are located. Vital Signs
Include relevant labs, BP: 121/76 HR: 76 RR: 18 SPO2: 97% T: 98.5
test results, vitals, and Pain: 0/10
Height: 5’5 Weight: 130 BMI: 21.6 normal
Review of Systems
Diagnostic results:
(ROS) – if ROS is
GAD-7 : score 10, which indicates moderate anxiety
negative, “ROS
Thyroid function test, CBC, CMP, Troponin: Normal
noncontributory,” or
Toxicology screening: negative
“ROS negative with
BAC level: normal
the exception of…”
ECG: Normal
Include MSE, risk
Mental status examination
assessment here, and
He is a 45-year-old Caucasian female who is in dressed
psychiatric screening
appropriately, has a clean appearance, and seems her stated age.
measure results.
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.
Assessment Diagnosis
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
This is where the Objective data
“facts” are located. Vital Signs
Include relevant labs, BP: 121/76 HR: 76 RR: 18 SPO2: 97% T: 98.5
test results, vitals, and Pain: 0/10
Height: 5’5 Weight: 130 BMI: 21.6 normal
Review of Systems
Diagnostic results:
(ROS) – if ROS is
GAD-7 : score 10, which indicates moderate anxiety
negative, “ROS
Thyroid function test, CBC, CMP, Troponin: Normal
noncontributory,” or
Toxicology screening: negative
“ROS negative with
BAC level: normal
the exception of…”
ECG: Normal
Include MSE, risk
Mental status examination
assessment here, and
He is a 45-year-old Caucasian female who is in dressed
psychiatric screening
appropriately, has a clean appearance, and seems her stated age.
measure results.
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.
Assessment Diagnosis
