CASE STUDY INSOMNIA 31 YEOR OLD MALE

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
Hydroxyzine: 50 mg daily at bedtime

Decision Point One

Trazodone 50 mg po 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 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 Point Two

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
Decision Point Three
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 the 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 reassess in 4 weeks.