Please Read the Instructor Plan of care carefullyand my Answer to the question. answer the Instructor Question in APA format references well cited on the text and references no more than 5 years old. Thank you. Please also read the last paragraph to make sure everything is cover in the answer.

Instructor Question
When reading my work up and plan of care, consider me to be your collaborating physician. And, considerST to be your patient. For the purposes of this exercise, you have treated ST as you stated below. If my treatment plan (remember consider me as your collaborator for this exercise) aligns with you have provided below, then you and your collaborator agree...all done for you! If my treatment plan is the opposite of what your have provided above, is missing key elements of your work up and/or plan, or has additional elements that you did not discuss, please convince me (remember consider me as your collaborator for this exercise) why what you have proposed is a better plan of care than what I have...please use evidence to defend your position. Lastly, if you are not able to convince me, your collaborator, that your plan of care is the most appropriate based on the evidence, what would you do? Would you proceed as you originally planned? If yes, why? If no, why not? I think this is going to be fun!!!

Question: (myAnswer)

ST is a twenty-five-year-old male who presents to the clinic with a major complaint of insomnia. He has been experiencing problems sleeping for the past month. He has been “borrowing” medication from his mother and friends, such as diazepam and alprazolam, and he finds that these are helpful in allowing him to sleep. He was also diagnosed with asthma at the age of ten. He has been using an inhaler, as needed, but he cannot recall the name of the inhaler. He is currently working part-time through a temporary agency, and he has not been able to find any full-time work. Answer the following questions:

• What additional information would you like to obtain from ST?
• What are the possible reasons for his insomnia?

What are the possible strategies you can use to help him with the insomnia?

Additional Information Needed

The first pieces of additional information that is needed at this point are the other side effects the patient has been experiencing along with insomnia. Is St living at home with Mom and Dad or living with friends? What kind of inhaler has he been using? What triggers the need for the use of the inhaler? How long has he been without a regular doctor to treat these symptoms? How long has ST been purchasing illegal, narcotic, street drugs to self-medicate? How much of the medication has ST been taking? How many milligrams and how often has it been taken?

Probable Causes of Insomnia

The most likely causes of his insomnia are the stress of not having enough income and having a dependency on powerful, narcotic, drugs that are being obtained illegally. Having an addiction to these drugs can cause a chemical dependency requiring the person to have it to be able to get any sleep at all (Pigeon, Bishop & Marcus, 2013).

“The effects of diazepam on the stress-induced increase in extracellular dopamine and norepinephrine in the medial prefrontal cortex” (Finlay, Zigmond, & Abercrombie 1995), means that this drug can significantly increase stress like symptoms when one goes without the medication. One could very easily overdose on either one of these medications.

Possible Treatment Strategies

Benzodiazepine including Valium and Xanax (diazepam and alprazolam) are very suitable strategies in treating and maintain a healthy lifestyle while having insomnia but can cause long term dependency on the drug if used in excessive amounts over an extended period (Woo & Wynne, 2012). When recommending medication for the patient to take there would be a couple I would have to study and choose from; including diazepam and alprazolam which are great “prescription medications for insomnia include sedatives, tranquilizers, and anti-anxiety drugs” if used in small doses (Pigeon, Bishop & Marcus, 2013). It is also essential to make sure the patient is getting plenty of exercises and has a good diet because these can affect any medications given. But, before deciding on the prescribing dose or medication for this patient I would like to collect additional information that is needed, a detail health history and physical assessment to select the best plan of care for this patient.

References

Finlay, J. M., Zigmond, M. J., & Abercrombie, E. D. (1995). Increased dopamine and norepinephrine release in medial prefrontal cortex induced by acute and chronic stress: Effects of diazepam. Neuroscience, 64(3), 619-628. doi:10.1016/0306-4522(94)00331

Question : ST, 25 y/o male with insomnia ( Instructor plan of care)

HPI: 25 y/o male with complaints of insomnia (Location) x 1 mo (Onset). He characterizes his insomnia as major (How bad is it) and reports he has gotten Valium and Xanax (what have you Tried) from family and friends in the past to help with his symptoms. He reports a history of asthma--dx age 10, for which he uses prn medications (???Ventolin). He also reports (Other info) he is working part time for a temp agency as he has not been able to find full time employment.

What additional information would you like to obtain from ST? I would inquire about the Characteristics of his insomnia...do you have trouble falling asleep or do you have trouble staying asleep? Because you are unable to sleep at night, do you find yourself sleeping during the day (Associated factors/aggravating factors)? I would also ask ST how many hours of sleep, if any, that he gets per night (Duration)...what time do you go to sleep? What time do you usually get up? What do you consider a good nights sleep to be? When was the last time you got what you would consider a good nights sleep? When you were able to get this good nights sleep, do you do anything in particular to facilitate your sleep (Relieving factors)? Other information that I would obtain would include information on the mg dose of Xanax and Valium taken to help with sleep? I would also ask ST about the frequency with which he takes or has taken the Xanax and Valium...is it nightly? I would also ask about any other co-morbidities, chronic health conditions? I would ask about any other symptoms...palpitations, hot sweats, leg pain, numbness/tingling, Headache, feeling as if legs won't stop moving, etc. I would inquire about depressive and/or anxiety type symptoms. I would inquire about substance abuse history. I would inquire about STs sleep environment...tv, noise, kids, etc. Objective data not provided that would be useful: height, weight, BMI. Obese individuals are more likely to have obstructive sleep apnea and often have problems with insomnia.

What are the possible reasons for STs insomnia? If a review of systems (ROS) for ST is neg (no palpitations, hot sweats, leg pain, numbness/tingling, headache, feeling as if legs won't stop moving, uncontrolled asthma; depression, anxiety requiring medication, etc) and a physiologic cause for his insomnia is ruled out, then I would seek to identify other reasons for his insomnia. Consideration would be given to the following as potential causes: anxiety related to financial stressors secondary to an inability to find full time work, dependence of pharmacologic methods to aid sleep (Xanax and/or Valium), poor sleep hygiene...day time sleeping. Poor sleep environment...tv on, noise, etc.


What are possible strategies to help with insomnia? The easiest thing to do for ST relative to treating his insomnia is to educate ST on proper sleep hygiene (see handout attached below). If after further questioning, ST reports he has been taking either Xanax or Valium daily for his insomnia, I would refer him to mental health/substance abuse for proper weaning off of those medications and for full mental health evaluation to ensure that ST does not have undiagnosed anxiety and/or depression. In reference to pharmacologic treatment, I would recommend more than OTC modalities as he is using Xanax and Valium now...2 medications that produce effects well above what any OTC medication may produce and while I do feel that OTC medications (melatonin) are valuable and effective in some instances, for ST I would prescribe something more. Thus, I would prescribe Hydroxyzine pamoate (Vistaril) 25mg 1-2 tabs po qhs pen. Hydroxyzine pamoate is an antihistamine that is indicated for the treatment of insomnia. Is is non-narcotic and thus non-addicting. I would educate ST to take the medication as needed and to take it early enough to ensure that he get 8-9 full hours of sleep. Hydroxyzine pamoate is generally a benign drug and has the typical run of the mill side effects (dizziness, nausea, fatigue, etc.).

My assessment and plan (A/P) for visit 1:
1. Obtain through history and rule out physiologic cause for insomnia (obstructive sleep apnea based risk on BMI and neck circumference. If obese, order sleep study; rule out restless leg syndrome, peripheral neuropathy, carpal tunnel syndrome, or any other pain syndrome that may be interfering with sleep; evaluate for depression and anxiety with screening PHQ 2...if positive, provide full PHQ 9 and refer mental health; ensure asthma is adequately controlled through peak flow assessment and/or asthma severity index; rule out gastroesophageal reflux disorder...GERD; rule out thyroid conditions; etc.).
2. If physiologic cause identified, treat according to standard of care
3. If physiologic cause not identified, educate and encourage proper sleep hygiene
4. If mentally stable (neg PHQ score and/or +PHQ score but cleared by mental health), prescribe Hydroxyzine pamoate 25-50mg po qhs prn and educate patient on side effects
5. Provide ST with follow up appointment in 4 weeks.

References

http://www.mdedge.com/currentpsychiatry/article/64...

http://www.rehabs.com/pro-talk-articles/how-to-tre...

That's it! How did I do? Does your work up and plan of care align with what I have detailed here? Remember, for this exercise, I am your collaborator. And, this is my response to what you have presented to me as your work up and plan of care. If we are on the same page...your work is done. If we are not, tell me why your work up, non-pharmacologic strategies, and/or pharmacologic treatments are better options...use the evidence to form your arguments (The objective of this is to demonstrate that there are several methods that may be employed by providers to manage their patients. And, there may be differences of opinion relative to the work up and plan. However, as long as your work up and plan meets the minimum standard of care, you are ok, as your plan of care does not have to exactly match the plan of care of another provider! So be confident in your decisions and don't be afraid to hold the line in certain circumstances...our collaborators may challenge us but we have to prove to them that we know what we are doing!)