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Assessing and Treating Patients with Sleep/Wake Disorders
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Assessing and Treating Patients with Sleep/Wake Disorders
Introduction
Insomnia is one of the most typical clinical manifestations for which most adults seek
medical care. Even though sleep is perceived as a strong and highly regulated biological drive,
the capacity to fall asleep at the right time and keep sleep without excessive waking is something
that is widely fragile and can be influenced by different factors. The identification of these
different factors is in context the core of insomnia treatment. The management of insomnia
demands the use of a stepwise method, starting with the endeavor to eradicate or at least lower
the contributing factors and comorbid diseases that affect the capacity of a person to attain
optimal sleep. Insomnia mostly responds just partially to the medication of person sleep-
impairing influences, nonetheless, and most patients need medication directed towards sleep
itself. The successful behavioral and pharmacologic methods to insomnia can simply be devised
once all contributing elements are fully noted and addressed (Laureate Education. 2016b). The
impetus of this paper is to examine the case of a 31-year-old male who presents to the office with
a chief complaint of insomnia. The patient has not been given a prescription of opiate analgesic
in the past four years.
Case Summary
The patient is a 31-year-old male who came to the medical facility and noted that his
insomnia had gotten progressively worse in the past six months. The patient reported that he has
never been a great sleeper but he is currently experiencing a lot of challenges falling asleep. The
issue of the patient started six months ago after he lost his fiancé Laureate Education. (2016b).
The patient reported that his condition was affecting his ability to carry out his jobs in the

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chemical firm that he works as a forklift operator. The patient mentioned that he uses
diphenhydramine to sleep but he does not like the side effects (Laureate Education. 2016b). The
patient reports that he falls asleep at work as a result of a lack of sleep from the night before. The
medical records of the patient clearly show that he had a history of opiate abuse, which started
after he broke his ankle in a skiing accident and was recommended to use hydrocodone/pap
(acetaminophen) to mitigate the acute pain management. The patient reports using alcohol to
assist him to fall asleep noted that he takes around four beers before going to bed.
Patient Assessment
In the process of assessing and examining the patient with insomnia, it is important to do
a comprehensive medical history and do a review of the mental health state of the patient. The
signs and symptoms reported by the patient required to be collected to provide quality medical
care to the patient. Based on the case of the patient, the passing of his fiancé was the main cause
of insomnia which is also affecting his ability to work. The patient mentioned that he uses
diphenhydramine to sleep but he does not like the side effects of this medication. He further
notes that he uses alcohol as one of the ways to sleep (Jaffer et al., 2017). The mental
examination of the patient revealed that he was alert and oriented to person, time, place, and
event. The patient maintains good eye contact and is dressed appropriately for the time of year.
The patient denies any auditory, visual hallucinations. Judgment, insight, and reality contact are
all intact. The patient denies suicidal/homicidal ideation and is future-oriented.

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1 Assessing and Treating Patients with Sleep/Wake Disorders Student’s Name University Name Professor Course Date 2 Assessing and Treating Patients with Sleep/Wake Disorders Introduction Insomnia is one of the most typical clinical manifestations for which most adults seek medical care. Even though sleep is perceived as a strong and highly regulated biological drive, the capacity to fall asleep at the right time and keep sleep without excessive waking is something that is widely fragile and can be influenced by different factors. The identification of these different factors is in context the core of insomnia treatment. The management of insomnia demands the use of a stepwise method, starting with the endeavor to eradicate or at least lower the contributing factors and comorbid diseases that affect the capacity of a person to attain optimal sleep. Insomnia mostly responds just partially to the medication of person sleepimpairing influences, nonetheless, and most patients need medication directed towards sleep itself. The successful behavioral and pharmacologic methods to insomnia can simply be devised once all contributing elements are fully noted and addressed (Laureate Education. 2016b). The impetus of this paper is to examine the case of a 31-year-old male who presents to the office with a chief complaint of insomnia. The patient has not been given a prescription of opiate analgesic in the past four years. Case Summary The patient is a 31-year-old male who came to th ...
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