Case Study BACKGROUND INFORMATION The patient is

Case Study BACKGROUND INFORMATION The patient is a 31-year-old male. He states that his insomnia has worsened over the past six months. Per the patient, he has never been a “great sleeper” but now has difficulty falling asleep and staying asleep at night. The problem began approximately six months ago after the sudden loss of his fiancé. The patient states this is affecting his ability to perform his job as a forklift operator at a local chemical company. The patient states he has used diphenhydramine to sleep but does not like how 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 before 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 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: Select what you should do: Trazodone: 50mg daily at bedtime (selected this option) Other options Zolpidem: 10mg daily at bedtime Hydroxyzine: 50mg daily at bedtime RESULTS OF DECISION POINT ONE Patient returns to the 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 the current dose. (selected this option) Other options Discontinue trazodone. Initiate therapy with suvorexant 10mg daily at bedtime Decrease trazodone to 25 mg daily at bedtime RESULTS OF DECISION POINT TWO Patient returns to the 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 the following day with next-day drowsiness Patient denies auditory/visual hallucinations and is future-oriented Decision Point Three: Select what you should do next Continue dose. Explain to the patient he may split the 50mg in half. The decreased dose should minimize next-day drowsiness. Follow up in 4 weeks. (selected this option) Other options Discontinue trazodone. Initiate therapy with hydroxyzine 50mg at bedtime. Follow up in 4 weeks Discontinue trazodone. Initiate therapy with sonata 10mg nightly at bedtime. Follow up in four weeks. Guidance Trazodone is a selective serotonin reuptake inhibitor with a low side effect profile. It would not be prudent to prescribe sonata as it carries 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 reassess in 4 weeks. Decision #1 Which decision did you select? Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources. 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. What were you hoping to achieve by making this decision? Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. Decision #2 Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources. 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? Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. Decision #3 Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources. 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. What were you hoping to achieve by making this decision? Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

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