Case Study: Anxiety

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BACKGROUND INFORMATION

Introduction 1 page body and conclusion 1 page

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

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature. All decisions have been chosen and highlighted for you see below.

Introduction to the case (1 page)

· Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.

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.

You administer the Hamilton Anxiety Rating Scale (HAM-A) which yields a score of 26.

Diagnosis: Generalized anxiety disorder

Decision Point One

Begin Paxil 10 mg po daily

RESULTS OF DECISION POINT ONE

· Client returns to clinic in four weeks

· Client 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)

Decision Point Two

Increase dose to 20 mg po daily

RESULTS OF DECISION POINT TWO

· Client returns to clinic in four weeks

· Client 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)

Decision Point Three

Maintain current does.

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 you 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.

Please use the patient case titled. White male with generalized anxiety”. See attachment. The attachment provided will be use to answer these questions above.

Please indicated reasons for not selecting treatment with the other two actions see below for reasons Not work as well as option 1.

Option #2 begging treatment with Imipramine 25 mg BID

· Client returns to clinic in four weeks

· Client reports a “slight” decrease in symptoms

· Client’s states that he no longer gets chest tightness, but still has occasional episodes of shortness of breath

· HAM-A score decreased from 26 to 22

Option #3 begging treatment with Buspirone 10 mg BID

· Client returns to clinic in four weeks

· Client reports slight decrease in symptoms

· Client states that he still feels very anxious

· HAM-A score decreased from 26 to 23