Assignment 2: Assessing and Treating Patients With Sleep/Wake Disorders

1/16/22, 8:34 PM Psychopharmacologic Approaches to Treatment of Psychopathology

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Insomnia 31-year-old Male

BACKGROUND This week, we examine a 31-year-old male who presents to the o�ce 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 di�culty both falling asleep and staying asleep at night. The problem began

approximately 6 months ago after the sudden loss of his �ancé. The patient states this is

a�ecting 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

1/16/22, 8:34 PM Psychopharmacologic Approaches to Treatment of Psychopathology

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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, 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.

Decision Point One Select what you should do:

Zolpidem: 10 mg daily at bedtime

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Trazodone 50 mg po at bedtime

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Hydroxyzine: 50 mg daily at bedtime

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