SUBJECTIVE: Patient is a 31-year-old male

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.

 

Selected Decision: 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
Explain that an erection lasting 15 minutes is not considered a priapism and should diminish over time, continue with current dose

 

OTHER OPTIONS:
Discontinue trazodone. Initiate therapy with suvorexant 10 mg daily at bedtime

or

Decrease trazodone to 25 mg daily at bedtime

 

 

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 #2

 

1.     Was this a good choice to select? based on the other 2 options, Be specific and support your response with clinically relevant and patient-specific resources.

2.    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.’

3.    What were you hoping to achieve by making this decision? Support your response with evidence and references

4.    Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.