Soap Note discussion

SOAP

 Plan (P)

Diagnostics

Physical examination.

Blood test to rule out the possibility of other underlying medical conditions.

Therapeutic

Doxepin 3-6 mg per day to help with falling and staying asleep.

Lorazepam 1-10 mg per day to help treat anxiety.

Recommend counseling to change drinking behavior.

Educational

The patient should create and follow a consistent sleep schedule. Sleeping time should be consistent every day (Bragg et al., 2019). The authors suggest that medication should be prescribed to the patient as a temporary mode of action.

Breathing exercises help relieve anxiety, lower heart rate, and promote muscle relaxation.

Caffeine and alcohol. These compounds are hard to sleep, and their effects can last for several hours. Consumption of alcohol causes a fragmented night’s sleep. According to Britton et al. (2020) to alcohol is related to chronic sleep problems. The research reveals that more men take alcohol compared to women. The male participants who consume alcohol also report chronic sleep problems.

Commit part of the day to exercise. Activity will help with sleep and other underlying conditions like obesity.

Consultation/ Collaboration

Consult a sleep physician to get a detailed diagnosis of the primary sleep disorder.

Collaborate with therapists to help counsel the patient for alcoholism (Watkins et al., 2017). According to the researchers, collaborative care-based interventions prove effective in rehabilitating alcoholism. The study conducted by the scholars involved a total of 377 participants randomly divided to receive usual care ad collaborative care. The proportion of participants who received a collaborative care plan benefited from the study, with many of them abstaining from alcohol and opioid abuse.

References

Bragg, S., Benich, J. J., Christian, N., Visserman, J., & Freddy, J. (2019). Updates in insomnia diagnosis and treatment. The International Journal of Psychiatry in Medicine54(5), 275-289. https://doi.org/10.1177/0091217419860716

Britton, A., Fat, L. N., & Neligan, A. (2020). The association between alcohol consumption and sleep disorders among older people in the general population. Sci Rep5275(10). https://doi.org/10.1038/s41598-020-62227-0

Watkins, K. E., Ober, A. J., Lamp, K., Lind, M., Setodji, C., Osila, K. C., Hunter, S. B., McCullough, C. M., Becker, K., Iyiewuare, P. O., Diamant, A., Heinzerling, K., & Pincus, H. (2017). Collaborative Care for Opioid and Alcohol Use Disorders in Primary Care. JAMA Internal Medicine177(10), 14480-1488. https://doi.org/ 10.1001/jamainternmed.2017.3947


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