Question

A 52-year-old woman complains that she has been missing days of work almost every week, she states she is neglecting her family, and she is sleeping during the day but cannot sleep at night. She denies other health problems, medication, or environmental allergies.

Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.

In SOAP format, list: Pertinent positive and negative information Differential and working diagnosis Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.

Answer 1

As the patient is having sleeping disturbances, you can ask the following questions

-How often does she miss her work days in a week?

-How often does she have trouble going to sleep or staying asleep during night?

-Does she have difficulty in concentrating?

-Does she have difficulty in staying awake while sitting still,reading or watching tv?

-How many hours does she sleep during the daytime?

-what was her sleeping habits before and since when the habit changed?

-is there any history of loud snoring ?

-Is there any history of sleep apnoea?

-Does she need any caffeinated drinks to stay awake?

-How does she feel regarding her family and what's the family's reaction towards her changed sleeping pattern?

Apart from these physical examination should be done giving importance to central nervous system, musculo skeletal system , respiratory system, gastro intestinal system and cardio vascular system. Patient should be asked for any type of stress , anxiety or any other existing disease conditions.

Subjective : - she described regarding her sleep pattern

-she told that she sleeps during daytime

-she expressed her anxiety regarding her missing work days because of her changed sleeping habit

-she worried about her family that she is not able to take care of them properly

Objective : -Note the vital signs of the patient

-relevant physical examination are to be noted.

-sleep study reports are to be noted

Diagnosis : Possible diagnosis is Circadian rhythm sleep disorder in which the circardian rhythm of patient is disrupted and the patient feels sleepy during inconvenient times. Differential diagnosis are insomnia, Narcolepsy and delayed sleep phase disorder.

Treatment plan :

The following tests are to be conducted - Polysomnography (PSG - Its a lab evaluation that checks oxygen levels, body movements and brain waves to determine how they affect sleep),EEG and Multiple sleep latency test (MSLT- Its a daytime sleeping study)

-Encourage daytime physical activities

-encourage to take milk during bedtime

-instruct to follow a strict schedule for work , rest and sleep

-instruct to avoid large amount fluids before bedtime

-encourage to do relaxing activities like warm bath, calm music or relaxation excercises

-instruct the patient to keep a sleep dairy

-instruct to avoid stress and anxiety

medications include - benzodiazepines ( eg ; alprazolam , clonazepam, diazepam )

-Non benzodiazepine hypnotics ( eg ; zaleplon, zolpidem)

-Melatonin receptor stimulator ( eg : ramelteon )

-Anti narcoleptics ( eg : methyphenidate, modafinil )

-Anti anxiety medications ( eg : quetiapine, mitrazepine, olanzepine)

-Orexin receptor antagonist ( eg : lemborexant, suvorexant )

-Anti parkinson agents ( eg : gabapentine, pramipexole )

OTC therapy with anti histamine drugs ( eg : chlorpheneramine maleate ) can also be done

Lifestyle changes to be followed are

-reduce stress and anxiety by practicing exercise or yoga

-limit caffiene intake after 6pm

-minimise tobacco and alcohol use

-create a sleep wake pattern and try to srictly practice as much as possible

-avoid drinking much fluids before bedtime

-have low carbohydrate meals for dinner. have more vegetables in diet.