Subjective
HPI: Ms. Jones presents to the clinic reporting difficulty sleeping, a concern she mentions having experienced for the past month. She describes her sleep as “shallow and not restful” and notes a particular difficulty with xxx. On average, she sleeps approximately 4 to 5 hours per night and wakes up at 8:00 am daily. Ms. Jones maintains a relatively consistent schedule on both weekdays and weekends. She does not use any prescription or over-the-counter sleep aids and adopts healthy sleep practices such as limiting screen time before bedtime and avoiding caffeine intake after 4 pm daily. Over the past month, she has experienced xxx. While she denies difficulties waking up, she expresses dissatisfaction with her morning restfulness, reporting daytime fatigue (severity rated 5/10), restlessness, and irritability (severity rated 2/10). She does not take xxx.
Social History: Stress related to upcoming examinations and the impending job search post-graduation is acknowledged. Ms. Jones, however, highlights having a robust support system comprising friends and family, and active involvement in her church. She copes with stress by staying organized and engages in leisure activities such as reading and watching television (1-2 hours per day). She acknowledges xxx. Ms. Jones denies tobacco use, consumes approximately 10-12 alcoholic beverages per month (never exceeding 3 per sitting), with no apparent impact on her sleep. While she has a history of marijuana use, she currently abstains from it and denies the use of other illicit drugs. She does not xxx but notes xxx daily. Additionally, she drinks 1-3 diet colas per day.
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Family History: There is no known history of sleep disorders or psychiatric conditions within the family.
Review of Systems:
– General: Denies changes in weight, weakness, fever, chills, and night sweats. Does complain of xxx.
– 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: Describes her mood as “off” and not feeling like herself. Reports increased anxiety related to upcoming exams and job search. No history of depression, but acknowledges feelings of helplessness and declining performance at work and school. 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 monitoring symptoms and maintain a log of insomnia episodes and associated anxiety factors for the next visit.
– Advise her to decrease caffeine consumption and increase water and fluid intake.
– Provide education on xxx. Continue to xxx.
– Discuss the importance of maintaining a regular sleep schedule and adopting sleep hygiene practices, such as limiting caffeine after 2 pm, fluids after dinner, and screen time or stimulating activities after 8 pm. Also, advise getting out of bed if awakened in the middle of the night.
– Educate Ms. Jones on xxx and depressant medications (including diphenhydramine and Tylenol PM).
– Provide guidance on when to seek further or emergent care, especially if experiencing feelings of self-harm or hopelessness.
– Schedule a follow-up clinic visit in 2-4 weeks for further evaluation.
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.
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