Chief complaint of insomnia.

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BACKGROUND
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
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 orient
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
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.

Sample Solution

similarly, Vittola expresses the quantity of army techniques used, but by no means reaches a conclusion whether or not it’s lawful or not to proceed those actions, as he continuously discovered a middle floor, in which it can be lawful to do such matters however in no way usually (Begby et al (2006b), page 326-31). that is supported by means of Frowe, who measures the valid approaches consistent with proportionality and navy necessity. It relies upon at the magnitude of how an awful lot damage executed to each other, so as to decide the movements after a warfare. as an instance, one can’t absolutely nuke the terrorist corporations all through the center-east, as it isn’t handiest proportional, it’s going to harm the complete population, an unintentional result. greater importantly, the soldiers should have the right aim in what they’re going to attain, sacrificing the charges to their actions. for instance: if squaddies need to execute all prisoners of conflict, they should do it for the proper goal and for a just motive, proportional to the harm carried out to them. that is supported by means of Vittola: ‘no longer usually lawful to execute all combatants…we must take account… scale of the damage inflicted through the enemy.’ that is further supported by means of Frowe technique, which is a lot more moral than Vittola’s view however implies the identical agendas: ‘can’t be punished simply for fighting.’ this means one cannot really punish every other because they have been a combatant. They should be treated as humanely as possible. however, the scenario is escalated if killing them can result in peace and security, within the interests of all events. usual, jus in bello shows in wars, harm can best be used in opposition to fighters, never against the harmless. but in the end, the goal is to establish peace and safety inside the commonwealth. As Vittola’s conclusion: ‘the pursuit of justice for which he fights and the defence of his native land’ is what nations ought to be preventing for in wars (Begby et al (2006b), page 332). for that reason, although these days’s world has developed, we are able to see now not an awful lot one-of-a-kind from the modernist accounts on struggle and the traditionists, giving every other section of the concept of the simply war. despite the fact that, we will nevertheless conclude that there can not be one definitive idea of the just struggle theory because of its normativity.
Jus publish bellum
sooner or later, jus post bellum shows that the actions we ought to take after a struggle (Frowe (2010), web page 208). first off, Vittola argues after a struggle, it’s far the obligation of the leader to choose what to do with the enemy (Begby et al (2006b), web page 332).. once more, proportionality is emphasized. for instance, the Versailles treaty imposed after the first global conflict is questionably too harsh, as it become not all Germany’s fault for the warfare. that is supported by Frowe, who expresses two views in jus post bellum: Minimalism and Maximalism

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