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.
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, 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
Trazodone: 50–100 mg daily at bedtime
Hydroxyzine: 50 mg daily at bedtime
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31-year-old Male
31-year-old Male
Decision Point One
Trazodone: 50–100 mg daily at bedtime
RESULTS OF DECISION POINT ONE
Patient returns to clinic in 2 weeks
Patient states medication works well but gives him an unpleasant side effect of a prolonged erection of the
penis, approximately 15 minutes after waking
Patient 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
Decision Point Two
Decrease trazodone to 25 mg daily at bedtime
RESULTS OF DECISION POINT TWO
Patient returns to clinic in 2 weeks
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Patient states trazodone is very effective for sleep
Patient states sometimes the 25 mg dosage isn’t quite enough to help him sleep through the night
Patient denies auditory/visual hallucinations and is future oriented
Decision Point Three
Discontinue trazodone. Initiate therapy with hydroxyzine 50 mg nightly at bedtime. Follow up in 4 weeks
Guidance to Student
Since the patient is already showing a partial response from trazodone, it may not be prudent to switch therapy.
A thorough sleep hygiene analysis should always be performed prior to initiation of pharmacotherapy as well
as at reassessments. If you find the patient isn’t practicing proper sleep hygiene, you may continue the dose
and encourage sleep hygiene. If the patient is practicing good sleep hygiene, you may consider discontinuing
trazodone and initiating hydroxyzine. Although there are some negative side effects associated with
hydroxyzine such as Xerostomia and Xerophthalmia, it is still a safer medication to prescribe than ramelteon.
Assignment 2: Assessing and Treating Patients With Sleep/Wake Disorders
Sleep disorders are conditions that result in changes in an individual’s pattern of sleep (Mayo Clinic, 2020). Not
surprisingly, a sleep disorder can affect an individual’s overall health, safety, and quality of life. Psychiatric
nurse practitioners can treat sleep disorders with psychopharmacologic treatments, however, many of these
drugs can have negative effects on other aspects of a patient’s health and well-being. Additionally, while
psychopharmacologic treatments may be able to address issues with sleep, they can also exert potential
challenges with waking patterns. Thus, it is important for the psychiatric nurse practitioner to carefully evaluate
the best psychopharmacologic treatments for patients that present with sleep/wake disorders.
Reference: Mayo Clinic. (2020). Sleep disorders. https://www.mayoclinic.org/diseases-conditions/sleepdisorders/symptoms-causes/syc-20354018
To prepare for this Assignment:
Review this week’s Learning Resources, including the Medication Resources indicated for this week.
Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of
patients with sleep/wake disorders.
The Assignment: 5 pages
Examine 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 patientspecific resources, including the primary literature.