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Case Study: A Middle-Aged Caucasian Man With Anxiety

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Case Study: A Middle-Aged Caucasian Man With Anxiety. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client's pharmacokinetic and pharmacodynamic processes.

Decision #1

Which decision did you select?

Why did you select this decision? Support your response with evidence and references to the Learning Resources.

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

Decision #2

Why did you select this decision? Support your response with evidence and references to the Learning Resources.

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

Decision #3

Why did you select this decision? Support your response with evidence and references to the Learning Resources.

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

Also include how ethical considerations might impact your treatment plan and communication with clients.

Finally: 1. Complete the decision tree (keep track of what you selected. come up with a rational reason why you chose it. Come up with patient specific rational reason behind not choosing the other two options not chosen).

2. Write paper addressing all section listed based on the decision tree.

Case Study: A Middle-Age Caucasian Man with Anxiety:

BACKGROUND INFORMATION:

The client is a 46-year-old white male who works as a welder at a local steel fabrication factory. He presents today after being referred by his PCP after a trip to the emergency room in which he felt he was having a heart attack. He stated that he felt chest tightness, shortness of breath, and feeling of impending doom. He does have some mild hypertension (which is treated with low sodium diet) and is about 15 lbs. overweight. He had his tonsils removed when he was 8 years old, but his medical history since that time has been unremarkable. Myocardial infarction was ruled out in the ER and his EKG was normal. Remainder of physical exam was WNL.

He admits that he still has problems with tightness in the chest and episodes of shortness of breath- he now terms these "anxiety attacks." He will also report occasional feelings of impending doom, and the need to "run" or "escape" from wherever he is at.

In your office, he confesses to occasional use of ETOH to combat worries about work. He admits to consuming about 3-4 beers/night. Although he is single, he is attempting to care for aging parents in his home. He reports that the management at his place of employment is harsh, and he fears for his job. You administer the HAM-A, which yields a score of 26.

Client has never been on any type of psychotropic medication.

MENTAL STATUS EXAM:

The client is alert, oriented to person, place, time, and event. He is appropriately dressed. Speech is clear, coherent, and goal-directed. Client's self-reported mood is "bleh" and he does endorse feeling "nervous". Affect is somewhat blunted, but does brighten several times throughout the clinical interview. Affect broad. Client denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, as is insight. He denies suicidal or homicidal ideation.

The PMHNP administers the Hamilton Anxiety Rating Scale (HAM-A) which yields a score of 26.

Diagnosis: Generalized anxiety disorder

RESOURCES

§ Hamilton, M. (1959). Hamilton Anxiety Rating Scale. Psyctests, doi:10.1037/t02824-0

Decisions Made and Outcomes (Needed to formulate the paper)

Choices for Decision 1: Select what the PMHNP should do:

1. Begin Zoloft 50 mg po daily
2. Begin Imipramine 25 mg po BID
3. Begin Buspirone 10 mg po BID

My decision: I chose to begin Zoloft 50 mg po daily.

Outcome: RESULTS OF DECISION POINT ONE:

Client returns to clinic in four weeks and informs you that he has no tightness in chest, or shortness of breath. Client states that he noticed decreased worries about work over the past 4 or 5 days. HAM-A score has decreased to 18 (partial response)

Choices for Decision 2: Select what the PMHNP should do:

1. Increase dose to 75 mg orally daily
2. Increase dose to 100 mg orally daily
3. No change in drug/dose at this time

My decision: I chose to increase dose to 75 mg orally daily.

Outcome: RESULTS OF DECISION POINT TWO:

 Client returns to clinic in four weeks and reports an even further reduction in his symptoms.

 HAM-A score has now decreased to 10. At this point- continue current dose (61% reduction in symptoms)

 

Choices for Decision 3: Decision Point Three Select what the PMHNP should do next:

1.  Maintain current dose
2. Increase current dose of medication to 100 mg orally daily
3.  Add augmentation agent such as BuSpar (buspirone) My decision: I choose to educate client regarding diet/weight loss and continue client on the same drug/dose

Outcome: Guidance to Student

At this point, it may be appropriate to continue client at the current dose. It is clear that the client is having a good response (as evidenced by greater than a 50% reduction in symptoms) and the client is currently not experiencing any side effects, the current dose can be maintained for 12 weeks to evaluate full effect of drug. Increasing drug at this point may yield a further decrease in symptoms, but may also increase the risk of side effects. This is a decision that the PMHNP should discuss with the client. Nothing in the client's case tells us that we should consider adding an augmentation agent at this point as the client is demonstrating response to the drug. Avoid polypharmacy unless symptoms cannot be managed by a single drug.