Write a SOAP note and prescribe lorazepam 0.5 mg sublingual (Ativan) as a single dose for an adult patient with MRI‑related anxiety and no contraindications.

SOAP Note for Single-Dose Sublingual Lorazepam for MRI Anxiety

Subjective

• Patient reports anxiety related to upcoming MRI procedure
• Assess for history of claustrophobia, previous MRI experiences, or panic symptoms
• Screen for contraindications: benzodiazepine allergy, acute narrow-angle glaucoma, severe respiratory disease (COPD, sleep apnea), current alcohol/substance use disorder, pregnancy/breastfeeding
• Document current medications to identify potential drug interactions
• Confirm no history of benzodiazepine dependence or withdrawal

Objective

• Vital signs: Blood pressure, heart rate, respiratory rate, oxygen saturation
• Mental status: Alert and oriented, baseline anxiety level
• Respiratory examination: Clear breath sounds, no respiratory distress
• Weight documentation (if available, though not required for single low dose)

Assessment

Primary diagnosis: Anxiety disorder related to medical procedure (MRI)

Clinical reasoning: Patient requires anxiolysis for procedural anxiety without contraindications to benzodiazepine use.

Plan

Prescribe lorazepam 0.5 mg sublingual tablet, dispense 2 tablets (1 mg total), for single-use administration 60-90 minutes prior to MRI. 1, 2

Rationale: The NICE guidelines support lorazepam 0.5-1 mg for anxiety management in adults, with sublingual administration explicitly noted as acceptable off-label use 1. The FDA-approved dosing for anxiety ranges from 2-6 mg/day divided, with 0.5 mg being appropriate for single-dose procedural anxiety 2. Prescribing 2 tablets (0.5 mg each) allows for dose adjustment if needed while maintaining safety—patient takes 1 tablet initially, with option for second tablet if anxiety persists after 30 minutes.

Specific Instructions to Patient:

Timing and Administration:

• Take 1 tablet (0.5 mg) sublingually 60-90 minutes before scheduled MRI
• Place tablet under tongue and allow to dissolve completely
• If anxiety remains significant after 30 minutes, may take second 0.5 mg tablet (maximum total dose 1 mg)
• Do NOT exceed 1 mg total dose

Safety Precautions:

• Do not drive to or from the MRI appointment—arrange transportation with responsible adult 2
• Avoid alcohol for 24 hours before and after medication use 2
• Expect drowsiness, dizziness, and slowed reactions for 4-6 hours post-dose 2
• Do not operate machinery or make important decisions for remainder of day

Warnings:

• Contact emergency services immediately if experiencing severe drowsiness, difficulty breathing, or inability to stay awake 2
• This is a controlled substance (Schedule IV)—do not share with others 2
• Single-use prescription only; not for ongoing anxiety management

Storage:

• Store at room temperature (68-77°F) in original container 2
• Keep out of reach of children and pets

Follow-up:

• No routine follow-up needed for single procedural dose
• If patient requires repeated MRI procedures with ongoing anxiety, refer to psychiatry or behavioral health for non-pharmacologic anxiety management strategies (cognitive behavioral therapy, relaxation techniques) 3
• Consider alternative anxiolytics or sedation protocols if benzodiazepines become contraindicated

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Clinical Pearls and Caveats:

Why sublingual route? Research demonstrates sublingual lorazepam achieves similar pharmacokinetics to oral administration (Tmax ~1.4 hours, similar bioavailability) while potentially offering faster onset 4. This is particularly useful for procedural anxiety where timing is critical.

Why 0.5 mg starting dose? This conservative approach minimizes risk of excessive sedation while providing adequate anxiolysis for most patients 1. Evidence from stereotactic breast biopsy studies shows 2-4 mg sublingual lorazepam effectively prevents vasovagal episodes, but MRI anxiety typically requires lower doses 5.

Common pitfall: Underdosing can lead to inadequate anxiety control and scan failure 6, but overdosing increases respiratory depression risk, particularly in elderly or those with respiratory compromise 2. The 0.5-1 mg range balances efficacy and safety for single-use procedural anxiety.

Special populations:

• Elderly/debilitated: Use 0.25-0.5 mg maximum 1
• Hepatic/renal impairment: Reduce dose or avoid; consult specialist 7
• Pregnancy: Avoid if possible; risk of neonatal sedation and withdrawal 2

Alternative consideration: If patient has contraindications to benzodiazepines or history of paradoxical reactions, consider non-pharmacologic interventions (music therapy, virtual reality, open MRI) or alternative anxiolytics under specialist guidance 3.

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Prescription Format:

Lorazepam 0.5 mg sublingual tablets
Dispense: 2 tablets
Sig: Take 1 tablet sublingually 60-90 minutes before MRI. May take 1 additional tablet if needed after 30 minutes. Maximum 2 tablets total. Do not drive after taking medication.
Refills: 0
DEA required (Schedule IV controlled substance)