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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. 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. Decision #1 (1 page) Which decision did you select? Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature. Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature. What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature). Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. Decision #2 (1 page) Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature. Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature. What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature). Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. Decision #3 (1 page) Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature. Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature. What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature). Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. Conclusion (1 page) Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature. 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. You administer 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: Decision Point One Select what you should do: Begin Paxil 10 mg po daily Begin Imipramine 25 mg po BID Begin Buspirone 10 mg po BID 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 One Begin Tofranil (imipramine) 25 mg orally BID RESULTS OF DECISION POINT ONE 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 Decision Point Two Increase Tofranil to 50 mg orally BID RESULTS OF DECISION POINT TWO Client returns to clinic in four weeks Client client reports that he was taken to the Emergency Room two weeks after the medication dose was increased. He was at work, and co-workers stated that he appeared to get “spacy” and lost consciousness. He states that the physician in the ER suggested that he stop taking the Tofranil because of an issue with his heart. The client brought a copy of his records from the ER, which included an EKG. The EKG shows right bundle branch block which was believed to have caused the clients syncopal episode. Decision Point One Begin Buspirone 10 mg orally BID RESULTS OF DECISION POINT ONE 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 Decision Point Two Increase buspirone to 10 mg orally TID RESULTS OF DECISION POINT TWO Client returns to clinic in four weeks Client reports no change in his anxiety HAM-A score has decreased from 23 to 22