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Posted: December 11th, 2022
Insomnia
Diagnostics: Ask the patient to keep a sleep log for 2 weeks to determine pattern of insomnia. Administer a self-report insomnia questionnaire, such as the Pittsburgh Sleep Quality Index. If they share a bed, collateral information about patient's sleep patterns should be obtained from patient's wife. Lab tests, including TSH and CBC (Arcangelo & Peterson, 2021; Kaur et al., 2022)
Therapeutic: Prescribe Trazodone 50 mg PO at bedtime. This medication has demonstrated efficacy for patients with comorbid anxiety. Refer patient for cognitive behavioral therapy to manage chronic insomnia (Arcangelo & Peterson, 2021).
Educational: Provide patient education for medication administration, side effects, and therapeutic outcomes. Provide patient education for improved sleep hygiene. Patient should be educated about the potential for alcohol consumption to exacerbate insomnia. Provide patient education for lifestyle changes, including diet and exercise, and their potential to reduce symptoms of insomnia (Kaur et al., 2022).
Consultation/Collaboration: Refer patient for cognitive behavioral therapy for management of chronic insomnia. Consider referral for polysomnography to determine the presence of sleep apnea. Patient may be referred for psychotherapy to address underlying anxiety and possible depression (Arcangelo & Peterson, 2021; Kaur et al., 2022).
Alcohol use
Diagnostics: Administer an alcohol use screening tool, such as the CAGE questionnaire. Assess patient for bipolar, depression, and anxiety disorders for differential diagnosis. Liver function tests (LFT) labs should be drawn to assess for any liver damage resulting from chronic alcohol use (Nehring & Freeman, 2022).
Therapeutic: First-line therapy is education and lifestyle changes. If these interventions are unsuccessful, then medications may be considered at a later date (Nehring & Freeman, 2022).
Educational: Patient should be provided education for alcohol use cessation or moderation. Patient should be educated on the physiological and psychological risks associated with excessive consumption of alcohol, including increased risk of cirrhosis of the liver and some cancers. Provide patient education for improving diet, exercise, and lifestyle (Nehring & Freeman, 2022).
Consultation/Collaboration: Patient may be referred for psychotherapy to address underlying anxiety and possible depression. Patient may be referred for cognitive behavioral therapy or other community resources for alcohol use cessation (Nehring & Freeman, 2022).
Plan (P):
1. Insomnia: The plan for insomnia is to start the patient on medication to help him sleep. He reports not being able to shut his brain off, anxiety, and worry. A benzodiazepine like Restoril may be a good sleep medication option for him, but due to the addictive dependency issues associated with benzos, I would want to start off with a non-benzo medication. I would ask the patient if they have tried melatonin or any other over-the-counter sleeping meds. If those had not been successful, I would start with Trazadone. Trazadone is a non-benzo sleeping medication that, in a literature review, was recommended for insomnia in 95.5% of the research studies. It's classed as a serotonin antagonist. It originated for depression but is much more commonly used for sleep. The patient would be started on 50 mg nightly. The patient would be scheduled for follow to evaluate sleep in two weeks (Jaffer et al., 2017). 2. Alcohol use:
The plan to help the patient with his alcohol use, besides starting him on medication for sleep, is to start him on medication to help him cut back on his alcohol intake. He reports that he uses alcohol to help him sleep. Hopefully, if his sleep improves, he will reduce his need to drink before bed. To help with his drinking, the medication Naltrexone would be prescribed. This medication works to help patients cut back on their alcohol consumption and reduces cravings for alcohol. It is the go-to first-line treatment for alcohol use disorders. The standard prescription is 50 mg once a day. Research has shown that alcoholic patients reduced their heavy drinking by 61% (UpToDate, n.d.).
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