Case Study of a 46-Year-Old White Male

Introduction

The case study presents a 46-year-old man who is a welder at a steel fabrication factory. The client presented after a referral by his PCP after he presented to the emergency room with fears about having a heart attack. The client reported that he was experiencing breath shortness, chest tightness, and a feeling of an impending doom. He also reported having a mild hypertension. His medical history is unremarkable. The findings from an EKG and ER were normal, ruling out a heart attack. The findings from the physical exam were within the normal limits. He revealed that he occasionally uses ETOH to get rid of his work worries. He also reports that he consumes around 3-4 beers per night. He further states that his workplace management is hard and thus he fears about his job. The MSE reveals that the client is appropriately oriented and his speech is clear and coherent. He reports feeling nervous. His affect is blunted. He denies any hallucinations. His judgment and insight are grossly intact. He denies any suicidal thoughts. The client’s HAM-A score is 26, confirming a diagnosis of generalized anxiety disorder (GAD). Some of GAD symptoms include persistent worry/anxiety, overthinking, feeling of impending doom, restlessness, concentration problems, [perceiving situations as threatening, among other symptoms (Costa & Manfro, 2019). The purpose of this paper is to discuss three treatment decisions for the client and outline the ethical considerations that guided each ethical decision.

Decision Point One

The client should begin on Zoloft 50 mg. The rationale for selecting the medication is due to its ability to increase serotonin levels in the brain and hence increases the amount of serotonin. As a result, the increased serotonin levels improve symptoms of GAD. Zoloft has also been demonstrated to be effective in treating anxiety disorders like GAD. Zoloft is an SSRI and thus among the first-line treatment choices for GAD (Strawn et al., 2018). Buspirone 10 mg was not chosen because it is a Serotonin-norepinephrine reuptake inhibitor and hence it has many side effects when compared to Zoloft. Imipramine 25mg was not selected because it is a tricyclic antidepressant and therefore a second-line treatment option for anxiety disorders like GAD (Locke et al., 2015).

By choosing Zoloft, it is hoped GAD symptoms like breath shortness, excessive anxiety, and chest tightness are likely to reduce due to the efficacy of Zoloft in improving GAD symptoms (Strawn et al., 2018). Zoloft has high tolerability and thus it is expected that the client will have minimal side effects after taking the medication.

Expectedly, when the client reported for assessment after four weeks there was significant symptom reduction as he reported symptoms such as breath shortness and chest tightness had reduced. He also reported reduced worry about his work and the HAM-A scored indicated a partial response to the Zoloft treatment. This is due to Zoloft’s efficacy in improving and decreasing GAD symptoms (Strawn et al., 2018). Secondly, he did not report any adverse effects after taking Zoloft medication and this shows that he tolerated the medication and the dosage well.

The ethical principle that guided this decision is informed consent. The client was educated about the available medications, including their side effects (Jauhar et al., 2019). This will enable the client to make an informed treatment decision.

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Decision Point Two

The dose should be increased to 75 mg. This is to increase the efficacy of the medication because a higher dose of Zoloft will avail more serotonin within the brain (Carvalho et al, 2016). The decision to have the Zoloft dose increased to 100 mg is not appropriate because dose increment should be gradual to ensure tolerability and avoid unwanted side effects. The decision to not change the dose was not selected because with the current dose the patient was showing partial response to the Zoloft dose.

The aim of increasing the Zoloft dose to 75 mg is to increase the efficacy of the medication and thus ensure that the client has complete remission of symptoms of GAD. Higher doses of SSRIs such as Zoloft lead to more availability of serotonin in the brain, leading to a better response and better symptom improvement (Bandelow et al., 2017). With Zoloft 75 mg, the aim is that he would tolerate this dose.

As per the expectations, the client reported further symptom improvement. The client reported that he was longer experiencing anxiety symptoms and the HAM-A score reduced further. This is attributable to the increased efficacy of Zoloft medication, by availing more serotonin within the brain, resulting in further improvement of the GAD symptoms (Romero-Martínez et al., 2019). Moreover, as anticipated, the client was able to tolerate a higher Zoloft dose as he did not report any side effects.

The ethical principle that guided this decision was informed consent and beneficence. The client was informed about the possible impact of increasing the Zoloft dose. Beneficence involved selecting a decision that would facilitate further symptom reduction (Munkholm et al., 2019).

Decision Point Three

The Zoloft dose should be maintained at 75 mg. The reason for this is because the client demonstrates a good response to this dose. He is also tolerating this dose because he never reported any side effect. The decision of increasing the Zoloft dose to 100 mg was not selected to avoid any possible side effects with a higher dose. The decision to augment the current medication was not considered as it is not viable clinically.

Maintaining Zoloft dose at 75 mg hopes that he will continue demonstrating good response, which will lead to complete symptom remission. This is due to the effectiveness of Zoloft as an SSRI in treating GAD symptoms. Moreover, the client is not expected to report any side effects because he is tolerating the Zoloft 75 mg well.

For the ethical principle, the client was educated about the mechanism of action of Zoloft, as well as the side effects such as the dependency of SSRIs (Jauhar et al., 2019). The client was educated about the necessary measures he can implement to prevent such side effects. The principle of non-maleficence also guided this decision by balancing the possible risks and benefits associated with each available treatment decision (Munkholm et al., 2019).

Conclusion

Zoloft 50 mg was selected as the treatment option for this client due to the efficacy of Zoloft in improving symptoms of GAD. Buspirone 10 mg was not chosen because it is an SNRI and hence it has many side effects when compared to Zoloft. Imipramine 25mg was not selected because it is a tricyclic antidepressant and therefore a second-line treatment option for anxiety disorders like GAD. The client manifested a partial response to Zoloft 50 mg and thus the next decision included increasing the Zoloft dose to 75 mg. Maintaining a Zoloft dose of 50 mg was not chosen since with this dose he manifested partial response, while the decision on increasing Zoloft dose to 100 was not chosen because dose increment ought to be gradual to avoid side effects. With the Zoloft 75, the client continued to manifest further symptom reduction as reported by the client and as manifested by a further decrease of the MAM-A score. The third decision was thus to maintain the current dose of Zoloft 75 mg as he was manifesting a good response. The decision of increasing Zoloft dose to 100 mg was not selected to avoid any possible side effects with a higher dose, while the decision to augment the current medication was not considered because there is no clinical reason to have Zoloft medication augmented. The ethical principles that guided the three decisions were informed consent as the client was educated about the medications as well as the possible dependency with Zoloft; beneficence and the ethical principle of non-maleficence.

References

Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93–107. https://doi.org/10.31887/DCNS.2017.19.2/bbandelow

Carvalho A, Sharma M, Brunoni A, Vieta E & Fava G. (2016). The Safety, Tolerability, and Risks Associated with the Use of Newer Generation Antidepressant Drugs: A Critical Review of the Literature. Psychiatry, 85(5).

Costa, M. D. A., & Manfro, G. G. (2019). Generalized anxiety disorder: advances in neuroimaging studies. Revista Brasileira de psiquiatria. São Paulo. vol. 41. n. 4 (jul./ago. 2019), p. 279.

Jauhar, S., Hayes, J., Goodwin, G. M., Baldwin, D. S., Cowen, P. J., & Nutt, D. J. (2019). Antidepressants, withdrawal, and addiction; where are we now? Journal of Psychopharmacology, 33(6).

Locke, A., Kirst, N., & Shultz, C. G. (2015). Diagnosis and management of generalized anxiety disorder and panic disorder in adults. American Family Physician, 91(9), 617-624.

Munkholm, K., Paludan-Müller, A. S., & Boesen, K. (2019). Considering the methodological limitations in the evidence base of antidepressants for depression: a reanalysis of a network meta-analysis. BMJ Open, 9(6), e024886. https://doi.org/10.1136/bmjopen-2018-024886

Romero-Martínez, Á., Murciano-Martí, S., & Moya-Albiol, L. (2019). Is Sertraline a Good Pharmacological Strategy to Control Anger? Results of a Systematic Review. Behavioral sciences (Basel, Switzerland), 9(5), 57. https://doi.org/10.3390/bs9050057

Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert opinion on pharmacotherapy, 19(10), 1057–1070. https://doi.org/10.1080/14656566.2018.1491966

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Casestudy:

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
Select what you should do:
-Begin Zoloft 50mg po daily
-Begin Imipramine 25mg po BID
-Begin Buspirone 10mg po BID

Questions

You are 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.

1-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.
2-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.
3- 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.

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4- 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.
5-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.

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