Date:
Patient:
Reason for Visit:
Follow-up for restless legs syndrome (RLS)
Assessment of symptom severity and response to treatment
Evaluation for sleep quality and impact on daily life
Management plan discussion
History:
Presenting Illness:
Date of initial RLS diagnosis
Characteristics of RLS symptoms (urge to move legs, discomfort, timing – worse at night)
Frequency and severity of symptoms (e.g., daily, occasional, mild, debilitating)
Impact on sleep quality (difficulty falling asleep, frequent awakenings)
Impact on daily activities (work, social life)
Past Medical History (PMH):
Underlying medical conditions (e.g., iron deficiency, neuropathy, pregnancy)
Prior medications or treatments for RLS
Social History:
Caffeine and alcohol intake (may worsen symptoms)
Sleep habits (regularity, bedtime routine)
Physical Exam:
General: Assess for overall health and signs of iron deficiency (pale skin, fatigue).
Neurologic: Evaluate for evidence of neuropathy (weakness, numbness, reflex abnormalities).
Diagnostic Tests (may be ordered depending on clinical suspicion):
Laboratory Tests:
Complete blood count (CBC) – Assess for iron deficiency (low ferritin, low iron saturation).
Serum iron studies (iron, ferritin, transferrin saturation) – Confirm iron deficiency if suspected.
Assessment:
Severity of RLS symptoms: Based on frequency, duration, and impact on sleep and daily life.
Possible underlying causes: Iron deficiency, neuropathy, pregnancy, other medical conditions.
Sleep quality: Evaluate sleep disturbances caused by RLS.
Impact on daily life: Assess limitations in work, social activities, and overall well-being.
Plan:
Treatment approach based on severity and underlying cause:
Iron therapy: If iron deficiency is present.
Dopamine agonists: Medication mainstay for moderate to severe RLS.
Calcium/magnesium supplements: May be helpful in some cases.
Lifestyle modifications: Regular exercise, good sleep hygiene, avoiding caffeine and alcohol before bed.
Consideration of referral to a sleep specialist or neurologist: For complex cases or difficulty managing RLS.
Patient education: Provide information about RLS, potential causes, and treatment options.
Discuss the importance of good sleep hygiene and healthy lifestyle habits.
Explain the role of medications and potential side effects.
Address the chronic nature of RLS and importance of ongoing management.
Follow-up:
Schedule for follow-up appointments based on treatment response:
More frequent visits for patients with initial treatment or uncontrolled symptoms.
Less frequent visits for patients with well-controlled RLS.
Encourage patients to report any worsening symptoms or side effects from medications.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of restless legs syndrome