Insomnia
31-year-old Male
BACKGROUND
This week, we examine a 31-year-old male who presents to the office with a chief complaint of insomnia.
SUBJECTIVE
Patient is a 31-year-old male. He states that his insomnia has gotten progressively worse over the past 6 months. Per the patient, he has never been a “great sleeper. But is now having difficulty both falling asleep and staying asleep at night. The problem began approximately 6 months ago after the sudden loss of his fiancé. The patient states this is affecting his ability to perform his job, which is a forklift operator at a local chemical company. The patient states he has used diphenhydramine in the past to sleep. But does not like the way it makes him feel the morning after. He states he has fallen asleep on the job due to lack of sleep from the night before.
The patient’s medical record from his previous physician states that he has a history of opiate abuse. Which began after he broke his ankle in a skiing accident. And was prescribed hydrocodone/apap (acetaminophen) for acute pain management. The patient has not received a prescription for an opiate analgesic in 4 years. The patient states recently he has been using alcohol to help him fall asleep, approximately four beers prior to bed.
MENTAL STATUS EXAM
The patient is alert and oriented to person, place, time, and event. He makes good eye contact and is dressed appropriately for time of year. He denies auditory/visual hallucinations. Judgement, insight, and reality contact are all intact. Patient denies suicidal/homicidal ideation, and is future oriented.
Point One
Select what you should do:
· Zolpidem: 10 mg daily at bedtime Trazodone 50 mg po at bedtime Hydroxyzine: 50 mg daily at bedtime
Decision Point One
Trazodone 50 mg po at bedtime
Results of decision point one
· Patient;
returns to clinic in 2 weeks
states medication works well but gives him an unpleasant side effect of an erection lasting approximately 15 minutes after waking
states this makes it difficult to get ready for work. Or go downstairs. And have coffee with his girlfriend and daughter in the morning
· Patient denies auditory/visual hallucinations and is future oriented
