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March 18, 2024

A 27 year old male presents to you today for an initial outpatient psychiatric evaluation for treatment of symptoms

A 27 year old male presents to you today for an initial outpatient psychiatric evaluation for treatment of symptoms of severe insomnia, nightmares and racing thoughts. The patient informs you he is only sleeping 2-3 hours a night. Reports both difficulty in falling and staying asleep. He indicates frequent nightmares occurring more nights than not and often when he gets “hot” at night. He has struggled with lack of sleep for several weeks and feels his symptoms of insomnia are getting progressively worse. Primary care provider ordered Ambien, which he reports “made me do strange things at nights”. Patient has self-discontinued the medication. Anxiety symptoms have increased as symptoms of insomnia worsen. Patient verbalizes when “I can’t sleep, I just get up and watch tv or play on my cellphone”. Chronic fatigue and low energy reported throughout the day. Client reports his work has been negatively impacted, as he feels his ability to focus and concentrate is poor.

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