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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Recommend and optimize appropriate sleep hygiene and nonpharmacologic therapies for the management and prevention of sleep disorders

  • Recommend and optimize appropriate pharmacotherapy for sleep disorders

  • Describe the components of a monitoring plan to assess safety and efficacy of pharmacotherapy for common sleep disorders

  • Educate patients about preventive behavior, appropriate lifestyle modifications, and drug therapy required for effective treatment and control of sleep disorders

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PATIENT PRESENTATION

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Chief Complaint

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"I'm so tired, can't talk right, feel shaky and my arms and legs don't want to work."

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History of Present Illness

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Miriam Weber is a 61-year-old woman who presents to the pharmacotherapy clinic complaining of feeling tired, uncoordinated, shaky, anxious, and mentally "foggy" for the past 4 days. In addition, she states that her speech has become slurred, which prompted her to go to the emergency department (ED) earlier today. At the ED, she was told to make an appointment with her regular physician as there were no urgent problems identified, but she has no medical insurance and typically receives all of her care and medications from the local free clinic, which is not open until tomorrow. On hearing of the situation, the physician in charge of the free clinic directed her to you for a medication evaluation. She presents with her husband and a basket full of medications. She asks you if you can recommend something for her to take for sleep. She has been taking a new medication, amitriptyline, for the past week and it does not seem to be working as she still cannot fall asleep at night.

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Past Medical History

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Hypothyroidism

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GERD

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Depression

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HTN

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Gastritis/duodenitis

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Migraine headache

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Insomnia

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Past Surgical History

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Total hysterectomy 20 years ago

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Family History

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Father had a history of DM and stroke. Mother has unknown cancer. Brother has "kidney problems" and alcoholism.

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Social History

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The patient is married and lives with and cares for her disabled husband and son as well as her elderly mother. She is currently unemployed. Family income consists of social security benefits from husband, son, and mother. She has no medical or prescription drug insurance.

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Tobacco/Alcohol/Substance Use

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(−) Tobacco and alcohol; (+) methamphetamine, patient has not used in 10 years after going through rehabilitation program.

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Allergies/Intolerances/Adverse Drug Events

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Cephalexin—hives; latex—rash

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Medications (Current)

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Citalopram 20 mg PO daily

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Amitriptyline 25 mg PO q hs

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Estradiol 1 mg PO daily

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Quinapril 20 mg PO daily

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