Psychiatric Soap Note 1: Insomnia – Is This A Soap Note Abou

Psychiatric Soap Note 1topic Insomniathis Is A Soap Note About A P

Subjective: The patient is a 45-year-old male presenting with complaints of persistent insomnia for the past three months. He reports difficulty falling asleep, waking up multiple times during the night, and feeling unrefreshed in the morning. The patient states that his sleep disturbances have led to increased irritability, difficulty concentrating at work, and feelings of fatigue during the day. He denies any recent changes in medication, substance use, or significant life stressors. The patient also mentions that he has a history of schizophrenia diagnosed five years ago and is currently stabilized on risperidone. He reports occasional auditory hallucinations, but these are not prominent at this time and do not interfere with his sleep symptoms. No other significant psychiatric symptoms reported.

Objective: Vital signs are within normal limits. The patient appears well-groomed but exhibits slight agitation during the interview. No overt signs of depression or anxiety are observed. Mental status examination reveals a cooperative attitude, normal speech, appropriate affect, and intact orientation. Cognitive function appears normal. No hallucinations or delusions observed during examination. Physical examination is unremarkable; laboratory results are pending but no abnormal findings are anticipated.

Assessment: The primary concern is primary insomnia in the context of stable schizophrenia. Insomnia may be exacerbated by psychotropic medication side effects, depressive symptoms, or underlying anxiety. Differential diagnoses include medication-related sleep disturbances, primary sleep disorder, or mood disorder. Given the absence of significant mood symptoms or anxiety, and stable schizophrenia, insomnia appears to be a primary issue possibly related to psychotropic medication side effects or sleep hygiene. The patient's ongoing schizophrenia stability suggests that sleep disturbances may be addressed without altering antipsychotic therapy at this time.

Plan: 1. Educate patient on sleep hygiene measures such as maintaining regular sleep schedule, avoiding caffeine and stimulants before bedtime, and creating a restful sleeping environment. 2. Consider sleep diary to monitor patterns. 3. Initiate low-dose trazodone (25-50 mg) at bedtime as adjunct therapy for sleep, monitoring for side effects. 4. Review current medication regimen; assess for potential side effects of risperidone contributing to sleep issues. 5. Schedule follow-up in two weeks to evaluate sleep improvement and medication adherence. 6. Continue psychiatric medications as prescribed for schizophrenia, monitor for any deterioration. 7. Refer to sleep specialist if sleep issues persist after initial interventions. 8. Reinforce the importance of maintaining medication compliance and attending regular psychiatric follow-up.

References

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• Freeman, D., et al. (2019). Insomnia and psychosis: A review of the literature. Schizophrenia Research, 206, 79–87.
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• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
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• Li, Z., et al. (2022). Pharmacologic management of sleep disturbances in schizophrenia: A review. Journal of Psychiatric Research, 151, 46-60.