Shadow Health Tina Jones Mental Health Documentation: HPI: Ms. Jones is presenting with difficulty sleeping, which she mentions started a month ago
Subjective
HPI: Ms. Jones is presenting with difficulty sleeping, which she mentions started a month ago. She describes her sleep as shallow and not restful, with an average of 4 to 5 hours per night and waking up at 8:00 am daily. Ms. Jones maintains a fairly consistent schedule on weekdays and weekends. She does not use prescription or over-the-counter sleep aids, limits screen time before bedtime, and avoids caffeine after 4 pm. Over the past month, she has experienced xx. Although she denies difficulties awakening, she feels unrefreshed in the morning and experiences daytime fatigue (severity rated 5/10), restlessness, and irritability (severity rated 2/10). Ms. Jones does not take xxx.
Social History: Ms. Jones experiences some stress related to upcoming examinations and her impending job search after graduation. She has a strong support system consisting of friends and family and is actively involved in her church. Coping with stress, she prioritizes staying organized, enjoys reading, and watches television for 1-2 hours daily. Ms. Jones has also experienced xxx. She does not use tobacco, consumes approximately 10-12 alcoholic beverages per month (never exceeding 3 per sitting), and has no noted impact on her sleep. While she used marijuana in the past, she currently abstains from its use and denies any other illicit drug use. Ms. Jones does not xxx, but xxx daily. She consumes 1-3 diet colas per day.
Family History: There is no known family history of sleep disorders or psychiatric disorders.
Review of Systems:
• General: Denies changes in weight, weakness, fever, chills, and night sweats. Complains of xxx.
• Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures. Reports changes in concentration and sleep. No changes or difficulties in coordination.
• Psychiatric: Ms. Jones reports feeling “off” in mood and not like herself. She experiences increased anxiety related to upcoming exams and job search. There is no history of depression, but she does feel helpless and notes 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 her symptoms and keeping a log of insomnia episodes and anxiety with associated factors to discuss during the next visit.
• Advise her to decrease caffeine consumption and increase water and other fluid intake.
• Provide education on xxx and maintain xxx.
• Discuss the importance of maintaining a regular sleep and wake schedule and implementing sleep hygiene techniques, including limiting caffeine after 2 pm, reducing fluids after dinner, avoiding stimulating activities after 8 pm, and getting out of bed if awakened in the middle of the night.
• Educate on xxx and depressant medications (including diphenhydramine and Tylenol PM).
• Provide information 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.
