Insomnia

Persistent difficulty with sleep initiation, maintenance, early awakening, or non-restorative sleep with daytime impairment, chronic if ≥3 nights/week for ≥3 months.

Assess sleep hygiene, screen time/caffeine/alcohol, shift work, psychiatric symptoms, medical comorbidities, medication review, snoring/apneas/restless legs symptoms.

Clinical, sleep history/diary (2 weeks). Screen for underlying cause (PHQ-9, GAD-7, medical review).

Polysomnography: not routine — reserved for suspected sleep apnea, periodic limb movement disorder, or diagnostic uncertainty.

Differentials: depression, anxiety, obstructive sleep apnea, restless legs syndrome, circadian rhythm disorders, medication/substance-induced, hyperthyroidism, chronic pain, menopause.

CBT-I — first-line, superior long-term outcome: sleep restriction, stimulus control, cognitive restructuring, relaxation techniques
Sleep hygiene: consistent schedule, avoid caffeine/alcohol near bedtime, limit screens, comfortable environment, avoid disruptive naps
Pharmacotherapy: short-term use only given dependence risk

Z-drugs (zolpidem 5-10mg, zopiclone 3.75-7.5mg nocte): limit to 2-4 weeks
Sedating antidepressants (amitriptyline, trazodone, mirtazapine): off-label, useful with comorbid mood disorder
Melatonin 2-5mg pre-bed: modest evidence, particularly circadian-related insomnia/elderly
Orexin antagonists (suvorexant, lemborexant): newer option, potentially lower dependence
Avoid long-term benzodiazepine/z-drug use — dependence, cognitive impairment, elderly fall risk

Treat underlying cause: comorbid depression/anxiety, pain, nocturia, sleep apnea (polysomnography, CPAP), restless legs (iron studies, ferritin target >75-100)

Referral: sleep medicine for suspected primary sleep disorder, refractory insomnia; psychiatry for significant mood/anxiety disorder.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Gastroesophageal Reflux Disease

Also known as: GERD, GORD, Reflux

Retrograde flow of gastric contents into the esophagus causing troublesome symptoms/complications, from transient LES relaxation, hiatal hernia, or impaired clearance.

Classified: non-erosive reflux disease (NERD most common), erosive esophagitis (Los Angeles grade A-D), Barrett's esophagus (premalignant metaplasia).

Clinical for typical symptoms without alarm features, empirical PPI trial reasonable.

Endoscopy if alarm features, age ≥55 new onset, or refractory. 24-hour pH/impedance monitoring: atypical symptoms, treatment-refractory, or pre-surgical evaluation.

Manometry: motility/pre-surgical workup.

Differentials: cardiac chest pain (exclude first), PUD, eosinophilic esophagitis (young, dysphagia, food impaction, atopy), achalasia, esophageal malignancy, functional heartburn.

Lifestyle: weight loss, elevate head of bed, avoid large/late meals, reduce triggers (fatty, spicy, caffeine, alcohol, chocolate, citrus), smoking cessation
PPI — first-line: omeprazole 20-40mg od, 30-60 min before breakfast; 4-8 week trial, step down to lowest effective/on-demand dose
H2RA (famotidine): add-on for nocturnal breakthrough
Alginates (Gaviscon): adjunct for post-prandial breakthrough
Refractory: reassess adherence/timing before assuming failure; investigate before dose escalation beyond standard
Barrett's: PPI therapy, surveillance colonoscopy per dysplasia grade
Surgical fundoplication: for refractory disease, patient preference to avoid long-term medication, large hiatal hernia, or PPI-refractory regurgitation — requires pre-op manometry/pH studies

Referral: gastroenterology for alarm features, refractory symptoms, Barrett's surveillance, surgical consideration.

Insomnia

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management