BACKGROUNDThis week, we examine a 31-year-old male who presents to the office with a chief complaint of insomnia. SUBJECTIVEThe 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 a 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 EXAMThe patient is alert and oriented to person, place, time, event. He makes good eye contact and is dressed appropriately for the time of year. He denies auditory/visual hallucinations. Judgment, insight, and reality contact are all intact. The patient denies suicidal/homicidal ideation and is future-oriented. Decision Point One Hydroxyzine: 50 mg daily at bedtimeRESULTS OF DECISION POINT ONE· patient returns to the clinic in 2 weeks· Patient states medication helps with sleep but leaves a similar next-day feeling to what the patient experienced with diphenhydramine· Patient also states his mouth and eyes are extremely dry in the morning· Patient denies auditory/visual hallucinations and is future-orientedDecision Point Two Decrease dose of hydroxyzine to 25 mg daily at bedtime RESULTS OF DECISION POINT TWO· patient returns to the clinic in 2 weeks· Patient states the decrease in dose has helped with the dry eyes, however, he is still not sleeping great· Patient denies auditory/visual hallucinations and is future-orientedDecision Point Three Discontinue hydroxyzine. Initiate therapy with trazodone 50–100 mg nightly at bedtime. Follow up in 4 weeks Guidance to Student Hydroxyzine is an antihistamine with strong sedative properties. However, many patients complain of anticholinergic adverse effects the following morning, such as Xerostomia and Xerophthalmia. Trazodone is a selective serotonin reuptake inhibitor that is a much more effective choice. In adults, you will want to start with 50mg at bedtime and titrate up as needed. The addition of diphenhydramine would augment the anticholinergic properties of the hydroxyzine that the patient is currently experiencing. The Assignment: 5 pagesExamine Case Study: Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.Introduction to the case (1 page)Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision-making when prescribing medication for this patient.Decision #1 (1 page)Which decision did you select?Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.Decision #2 (1 page)Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.Decision #3 (1 page)Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.Conclusion (1 page)Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature
