Sleep Consult

[Patient's age and gender](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a single line.) [Patient's chronic conditions](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List as bullet points.) Medications: [Patient's medications with doses](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading.) Presenting Complaint [Patient's primary complaint and any additional issues mentioned during the consultation](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Social History: (Only include if alcohol intake, caffeine intake, or exercise habits are explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Alcohol intake: [Patient's alcohol intake](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Caffeine intake: [Patient's caffeine intake](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Exercise: [Patient's exercise habits](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Sleep history: (Only include if sleep schedule details are explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Go to bed: [Patient's bedtime](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Get out of bed: [Patient's wake-up time](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Sleep onset: [Time taken to fall asleep](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Awakening: [Details of nocturnal awakenings](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Naps: [Details of any naps taken](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Epworth Sleepiness Score](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Presence or absence of sleep-related symptoms including loud snoring, snorts, gasps, witnessed apnoeas, insomnia, nocturnal wakenings, nocturnal urination, fatigue, daytime sleepiness, headaches, dry mouth, poor quality sleep, restless legs, and whether the partner sleeps in another room](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) On examination: [Vital signs including heart rate, oxygen saturation, and blood pressure](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write on a single line.) [Weight, height, and BMI](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write each on a new line.) Oral: [Mallampati score and presence of overbite, underbite, small chin, or thick neck](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading.) CVS: [Pulse regularity, heart sounds, and presence or absence of murmurs](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else write "Regular pulse, normal heart sounds, no murmurs".) Chest: [Lung sounds and air entry](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else write "Good air entry bilaterally, clear".) Assessment: [Likely diagnosis and any differential diagnoses as stated by the clinician](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading. Do not invent or infer a diagnosis.) Plan: [Management options discussed during the consultation](Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading.)