Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
New evaluation for suspected narcolepsy OR follow-up for established narcolepsy
(Specify) Symptoms of narcolepsy can vary but may include:
Excessive daytime sleepiness (EDS): Uncontrollable urge to sleep during the day
despite adequate nighttime sleep.
Cataplexy: Sudden loss of muscle tone triggered by strong emotions (laughter, anger, surprise).
Sleep paralysis: Inability to move or speak while falling asleep or waking up.
Hypnagogic/Hypnopompic hallucinations: Vivid dream-like experiences while falling asleep (hypnagogic) or waking up (hypnopompic).
History of Present Illness:
Onset, duration, and severity of symptoms, particularly focusing on EDS and cataplexy (hallmark symptoms).
Sleep habits: Nighttime sleep duration, quality of sleep, daytime napping habits.
Impact of symptoms on daily life (work, school, social activities).
Recent changes in sleep patterns or symptom severity.
Past Medical History:
Underlying medical conditions (e.g., neurological disorders, psychiatric conditions).
History of sleep disorders (e.g., sleep apnea, restless legs syndrome).
Medications currently taken (some medications can affect sleep).
Family History:
Family history of narcolepsy (uncommon but can be a risk factor).
Social History:
Lifestyle factors that can affect sleep (e.g., caffeine intake, alcohol use, shift work).
Social support system and impact of narcolepsy on social interactions.
Mental Status Examination:
Assess for alertness, mood, and cognitive function.
Screen for symptoms of depression or anxiety (common comorbidities with narcolepsy).
Sleep History Questionnaire:
Standardized questionnaires (e.g., Epworth Sleepiness Scale) can be used to assess daytime sleepiness.
Physical Exam:
General examination: Focus on signs of sleep deprivation (e.g., dark circles under eyes).
Neurological examination: Assess for coordination, reflexes, and any signs suggestive of neurological disorders.
Laboratory Tests:
Polysomnography (PSG) with Multiple Sleep Latency Test (MSLT): Gold standard for diagnosing narcolepsy.
PSG: Measures brainwaves, muscle activity, breathing, and eye movements during sleep.
MSLT: Measures sleepiness by assessing how quickly a person falls asleep after periods of wakefulness following an overnight PSG.
Hypocretin-1 (orexin-A) level testing (blood test): Low levels of hypocretin-1, a brain chemical involved in wakefulness, are supportive of narcolepsy diagnosis. However, this test is not routinely done due to cost and limited availability.
Imaging Studies:
Imaging studies are not typically used for diagnosing narcolepsy unless there is suspicion of an underlying neurological condition.
Assessment:
Suspected narcolepsy: Based on clinical presentation (EDS, cataplexy) and supportive findings on sleep studies (PSG/MSLT).
Confirmed narcolepsy: Based on PSG/MSLT findings meeting established criteria.
Narcolepsy type 1 (type 1 narcolepsy): Characterized by both EDS and cataplexy, associated with low hypocretin-1 levels.
Narcolepsy type 2 (type 2 narcolepsy): Characterized by EDS without cataplexy, normal or near-normal hypocretin-1 levels.
Differential Diagnoses:
Consider other conditions that can cause similar symptoms:
Sleep apnea
Idiopathic hypersomnia (excessive daytime sleepiness without cataplexy)
Shift work sleep disorder
Depression
Fatigue due to medical conditions
Plan:
Treatment:
Modafinil or armodafinil: First-line medications to promote wakefulness and improve EDS.
Sodium oxybate: Medication that can help suppress cataplexy and improve sleep quality (used in some cases, particularly for type 1 narcolepsy).
Tricyclic antidepressants: May be used for cataplexy and sleep paralysis.
Behavioral interventions: Sleep hygiene education, scheduled napping, and stress