Summary of visit: I arrived at patients home they were sitting outside waiting for me. She had company so I asked her if she wanted me to go at a different time she stated she was okay with me staying. I sat down and I asked her how she was doing she responded that besides her prior complaint she wanted to discuss her inability to sleep at night. She went on to describe her signs and symptoms. Her brother then approached me and he wanted to discuss diabetes management. We spoke about nutrition and he voiced he had discontinued his insulin and had started drinking every day. I gave him information in regards to the effects of alcohol and diabetes. We also discussed the possible effects of not following his treatment plan and not using his insulin. Patient stated he would start checking his blood sugar and take
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A: The patient has a diagnosis of narcolepsy which causes her to be fatigued throughout the daytime hours. She is taking frequent naps due to this cause which in turn cause her to be unable to sleep at night.
P: Patient will be able to establish an effective sleep pattern.
Short: Patient will be able to verbalize plan to implement sleep promotion routines by stating 3 measures to promote sleep by end of visit.
Long: Patient will be able to fall asleep without difficulty by falling asleep within 20 minutes of laying down within 1 month.
I: Educated patient on measures to promote an effective sleep pattern such as maintain herself active throughout daytime hours to minimize her naps. She is to take her prescribed medication for narcolepsy in the early morning instead of at 2p.m. as she currently is to minimize insomnia. She is to promote sleep by keeping environment quiet and dark.
E: Patient was very pleased with interventions suggested and will integrate them into her daily routines. She will report on the progress at next visit.
R: As of now no revisions noted. Patient will integrate
A: The patient has a diagnosis of narcolepsy which causes her to be fatigued throughout the daytime hours. She is taking frequent naps due to this cause which in turn cause her to be unable to sleep at night.
P: Patient will be able to establish an effective sleep pattern.
Short: Patient will be able to verbalize plan to implement sleep promotion routines by stating 3 measures to promote sleep by end of visit.
Long: Patient will be able to fall asleep without difficulty by falling asleep within 20 minutes of laying down within 1 month.
I: Educated patient on measures to promote an effective sleep pattern such as maintain herself active throughout daytime hours to minimize her naps. She is to take her prescribed medication for narcolepsy in the early morning instead of at 2p.m. as she currently is to minimize insomnia. She is to promote sleep by keeping environment quiet and dark.
E: Patient was very pleased with interventions suggested and will integrate them into her daily routines. She will report on the progress at next visit.
R: As of now no revisions noted. Patient will integrate