BACKGROUND This week, we examine a 31-year-old male who presents to the office w

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, 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 mg po at bedtime Trazodone
50 mg po at bedtime
Answer Trazodone 50mg 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 an
erection lasting 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
Select what you should
do next:
Explain that an erection lasting 15 minutes is not considered a priapism
and should diminish over time, continue with current dose
Discontinue trazodone. Initiate therapy with suvorexant 10 mg daily at
bedtime
Decrease trazodone to 25 mg
daily at bedtime
DECISION 2
Explain that an
erection lasting 15 minutes is not considered a priapism and should
diminish over time, continue with current dose
RESULTS OF DECISION POINT TWO
Patient returns
to clinic in 2 weeks
Patient states
priapism has diminished over time
Patient denies
auditory/visual hallucinations and is future oriented Patient states
trazodone is effective at 50 mg dose but sometimes wakes up following day
with next-day drowsiness Patient denies auditory/visual hallucinations and
is future oriented
· Select what you should do next:
· · Discontinue trazodone. Initiate therapy with sonata 10 mg nightly at
bedtime. Follow up in 4 weeks
· · Discontinue trazodone. Initiate therapy with hydroxyzine 50 mg at
bedtime. Follow up in 4 weeks
· · Continue dose. Explain to patient he may split the 50 mg tablet in half.
The decreased dose should minimize next-day drowsiness. Follow up in 4 weeks
· Decision Point Three
· Continue dose. Explain to
patient he may split the 50 mg tablet in half. The decreased dose should
minimize next-day drowsiness. Follow up in 4 weeks
Guidance to Student
Trazodone is a selective serotonin reuptake inhibitor
that has a low side effect profile. It would not be prudent to prescribe
sonata as it carries with it the risk of complex sleep behaviors.
Hydroxyzine is an antihistamine with strong sedative properties. However,
many patients complain of anticholinergic adverse effects the following
morning, such as Xerostomia and Xerophthalmia.
The patient is presenting
with excessive somnolence. It would be prudent to reduce the dose of trazodone
by 50% and reas