Treatment Plan and Notes: C.B.J., a 73-year-old female, was presented to the clinic by her daughter and grandson with complaints that C.B.J. feels that the medications she was using were not effective enough. C.B.J. had a Flurazepam prescription five days ago to help her manage her diagnosed insomnia. She is currently using Metformin and diet therapy to help manage her Type 2 Diabetes.

 
Treatment Plan and Notes:
C.B.J., a 73-year-old female, was presented to the clinic by her daughter and grandson with complaints that C.B.J. feels that the medications she was using were not effective enough. C.B.J. had a Flurazepam prescription five days ago to help her manage her diagnosed insomnia. She is currently using Metformin and diet therapy to help manage her Type 2 Diabetes.

C.B.J. appeared a bit fatigued during the examination and reported that she still found it hard to fall asleep for the most part of the night. She feels frustrated and concerned that the medications she was prescribed do not work and wants a replacement. She has no other concerns as of this day of examination. Despite C.B.J.’s symptoms and concerns, no new diagnosis was made during this visit.

For the treatment plan, C.B.J. will remain under the current medications for insomnia as well as the non-medical interventions that were previously discussed, including remaining active, taking the medications correctly and at the right time, as well as observing her lunch and dinner times and the times she takes her diabetes medications. The current regimen for insomnia will not be reviewed, and she will continue with the Flurazepam 15 mg taken orally once a day shortly before her bedtime. In case her symptoms do not improve, the medications will be reviewed, and the dosage will be increased to 30 mg only if need be. Her next appointment will be at the geriatric clinic on Thursday, June 29, 2023, at 9:30 AM. However, if there are other concerns over the efficacy of the current medications, she will be required to visit the clinic as needed