Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Evaluation for excessive daytime sleepiness (EDS) suggestive of a central disorder of hypersomnolence (CDH).
SOAP
Subjective (S):
Sleep History:
Inquire about sleep patterns, including:
Usual bedtime and wake-up time
Sleep duration (nighttime and naps)
Sleep quality (refreshing or unrefreshing)
Difficulty falling asleep or staying asleep (insomnia symptoms)
Presence of nighttime awakenings
Early morning awakenings (before desired wake-up time)
Explore for daytime sleepiness:
Frequency and severity of excessive daytime sleepiness (EDS)
Situations where sleepiness occurs (e.g., watching TV, monotonous tasks)
Difficulty staying awake during the day (sleep attacks)
Need for naps and their effectiveness in improving alertness
Medical History:
Briefly summarize relevant past medical history, including:
Underlying medical conditions that might contribute to sleepiness (e.g., neurological disorders, psychiatric conditions, sleep apnea)
Medications that can affect sleep-wake regulation
Social History:
Briefly inquire about:
Work or school schedule and impact of sleepiness on daily activities
Sleep hygiene practices (caffeine intake, alcohol use, screen time before bed)
Travel history (relevant for narcolepsy type 1)
Objective (O):
Mental Status Exam:
Assess alertness, orientation, and cognitive function.
Physical Exam:
Briefly document general appearance and any abnormal physical findings suggestive of underlying medical conditions.
Assessment (A):
Sleepiness Evaluation:
Based on the sleep history and daytime sleepiness characteristics, assess the severity of EDS according to established criteria (e.g., Epworth Sleepiness Scale).
Differential Diagnosis:
Consider various causes of EDS, including:
Central disorders of hypersomnolence (narcolepsy type 1 and 2, idiopathic hypersomnia, Kleine-Levin syndrome)
Sleep apnea (ruled out by sleep study if performed)
Circadian rhythm sleep-wake disorders
Medical and psychiatric conditions
Substance use disorders
Narrow the differential diagnosis based on the history, physical exam findings, and planned investigations.
Plan (P):
Sleep Study:
Schedule a polysomnography with Multiple Sleep Latency Test (MSLT) to definitively diagnose a central disorder of hypersomnolence and differentiate between types.
Laboratory Tests (if indicated):
Depending on the suspected CDH type or other considerations, order tests like:
Hypocretin-1 level (low levels suggestive of narcolepsy type 1)
Thyroid function tests
Autoimmune markers (e.g., anti-AQP4 for neuromyelitis optica)
Treatment Considerations (preliminary):
Discuss potential treatment options based on the suspected diagnosis, awaiting confirmatory testing:
Narcolepsy: Modafinil or sodium oxybate for promoting wakefulness and managing cataplexy (if present).
Idiopathic hypersomnia: Stimulants like modafinil to improve alertness.
Other CDHs: Treatment varies depending on the specific disorder.
Emphasize the importance of good sleep hygiene practices.
Follow-up:
Schedule follow-up appointments to discuss sleep study results, confirm diagnosis, and initiate definitive treatment plan.
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., sleep specialist)
Importance of addressing any identified underlying medical or psychiatric conditions
Educational resources provided to the patient about central disorders of hypersomnolence and their management
Referral for behavioral sleep medicine interventions if needed
Addressing potential impact of EDS on work, driving, and other activities