Which is most likely brought on by either stress

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Reference no: EM133408173

Subjective: The male patient is 45 years old and has had trouble sleeping for the previous two months. He states that he can fall asleep most of the time but that he wakes up often during the night and has trouble falling back asleep after each awakening. Even though he reports feeling weary throughout the day, he can still function normally and get through his day without significant issues. He also mentions that he sometimes has anxiety and overload but claims he can cope.

Objective: The patient exhibits weariness signs and states they are feeling weary. He claims he wakes up numerous times at night and has trouble falling or staying back asleep after each awakening. He is awake and focused, and there are no other outward manifestations of his sickness.

Assessment: The patient is most likely suffering from sleeplessness, which is most likely brought on by either stress or worry. There is a possibility that he is also going through a period of elevated stress and worry.

Plan: It will be recommended that the patient practice excellent sleep hygiene by avoiding coffee and other stimulants later in the day, maintaining a regular sleep schedule, and avoiding screens late at night. Will also provide a prescription for a gentle sleep aid that should be used only when absolutely necessary. Will further recommend the patient to a therapist for additional treatment of the patient's anxiety and stress levels. Will keep an eye on the patient's sleeping habits to determine whether or not the sleep aid is having the desired effect and will modify the dose as required.

Reference no: EM133408173

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