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NUR6630 wk 9 assg 2 - Week 9 assignment 2
Psychopharmacologic Approaches to Treatment of Psychopathology (Approaches to
Treatment) (Walden University)
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SUBJECTIVE
Patient is a 31-year-old male. He states that his insomnia has gotten
progressively worse in the last 6 months. The patient states he has never
been a “great sleeper” but is now having difÏculty both falling asleep and
staying asleep at night. The problem began about 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
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NUR6630 wk 9 assg 2 - Week 9 assignment 2
Psychopharmacologic Approaches to Treatment of Psychopathology (Approaches to
Treatment) (Walden University)
Scan to open on Studocu
Studocu is not sponsored or endorsed by any college or university
Downloaded by Splash Spashnet ()
, lOMoARcPSD|45010774
SUBJECTIVE
Patient is a 31-year-old male. He states that his insomnia has gotten
progressively worse in the last 6 months. The patient states he has never
been a “great sleeper” but is now having difÏculty both falling asleep and
staying asleep at night. The problem began about 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
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