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Posted: January 5th, 2023

The client is a 46-year-old white male who works as a welder

Examine Case Study:
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. The remainder of the 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.
The client has never been on any type of psychotropic medication. Diagnosis is Generalized anxiety disorder.
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. Please see the decisions I made below:
Decision Point One begin buspirone 10mg orally twice a day 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
Discontinue buspirone and begin Lexapro 10 mg orally daily
RESULTS OF DECISION POINT TWO
• Client returns to clinic in four weeks
• Client reports that he feels “great”
• Client states that his anxiety is getting “better”
• HAM-A score has decreased from 23 to 13
• Client does report that he sometimes feels sleepy for a few hours after taking the medication, but “perks up” by early to midafternoon
Decision Point Three
Continue same dose of Lexapro but change administration time to bedtime
Guidance and feedback to Student
At this point, the client reports that he is feeling “great” with a decrease in symptoms from an initial HAM-A score of 26 down to 13. This represents a 50% decrease in symptoms in just 4 weeks. Recall that an adequate trial can be as long as 12 weeks, we may not need to increase the drug any more at this point as we do not know how much more the current dose will improve the client’s symptoms. You could increase the dose, but this could increase the risk of side effects- especially the sleepiness that the client is complaining about in the morning after taking the medication. It is plausible that an increase in the dose would increase morning sedation.
The most prudent course of action would be to continue the same dose of medication but change the administration time to bedtime. This way, the client will not be troubled by the sedating effects of the medication, and sleep may be enhanced which could also improve overall anxiety.

Based on the information above, please answer questions below. 5 pages required.
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 make 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 (which are paxil 10mg orally daily and imipramine 25mg orally twice a day) 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 (which are increase busiprone to 10mg twice a day or 10mg three times a day) 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 (which are increase Lexapro to 15mg by mouth daily in the morning and restart Buspar to 10mg by mouth three times a day) 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.

Introduction to the case:
The client in this case is a 46-year-old male who has been experiencing symptoms of anxiety, including chest tightness, shortness of breath, feelings of impending doom, and the desire to “run” or “escape” from situations. He has a history of mild hypertension, has had his tonsils removed, and has a medical history that is otherwise unremarkable. He reports occasional alcohol use and work-related worries, and is caring for aging parents while working at a steel fabrication factory where he feels that management is harsh. An initial assessment using the HAM-A scale yielded a score of 26, indicating moderate to severe anxiety. The client has not previously been prescribed any psychotropic medications.

Decision #1:
For the first decision point, I selected to prescribe buspirone at a dose of 10 mg orally twice a day. I made this decision because buspirone is a medication that is commonly used for the treatment of generalized anxiety disorder, and has a relatively low risk of side effects compared to other options. In addition, the client in this case has not previously been exposed to any psychotropic medications, so starting with a lower-risk option may be a good way to gauge his response to treatment.

There is a good body of evidence supporting the use of buspirone for the treatment of anxiety disorders. In a review of randomized controlled trials, buspirone was found to be effective at reducing symptoms of generalized anxiety disorder, with response rates ranging from 35-50% (Lydiard et al., 2001). Another review of randomized controlled trials found that buspirone was superior to placebo in reducing symptoms of anxiety, and had a similar efficacy to other medications commonly used for anxiety disorders, such as selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines (Lader, 2002).

There are several factors that may impact the pharmacokinetic and pharmacodynamic processes of buspirone in this patient. One potential factor is the client’s mild hypertension, which may increase the risk of blood pressure changes with buspirone use. It is important to monitor blood pressure closely and adjust treatment as needed. Another potential factor is the client’s occasional alcohol use, as alcohol can interfere with the metabolism of buspirone and potentially increase the risk of side effects. It may be helpful to advise the client to limit or avoid alcohol use while taking buspirone.

The decision to prescribe buspirone at a dose of 10 mg orally twice a day was based on the evidence supporting its use for the treatment of generalized anxiety disorder, as well as the relatively low risk of side effects compared to other options. It is important to monitor the client’s response to treatment and adjust as needed, taking into account potential factors that may impact the pharmacokinetic and pharmacodynamic processes of the medication.

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