Case Scenario (decision Tree): A Middle-Aged Caucasian Man With Anxiety
worry disorders are the most common types of mental illnesses. They are marked by too much fear and problems caused by worry. People who have it have trouble concentrating, sleeping, and doing everyday things. Many people with this disease have physical symptoms like tight muscles and hypervigilance, which means they need to be checked for self-harm and other social problems. The old are among the most likely to be affected, especially those who already have health problems like heart disease or nerve disorders. But getting a correct evaluation and treatment can help people deal with their problems and feel better.
This talk is about anxiety disease and how different medicines can help treat it. The client is a white man who is 46 years old and has signs of a heart attack when he goes to the emergency room. The patient has tightness in the chest, shortness of breath, and a feeling that something bad is going to happen. He weighs about 15 pounds more than he should, and he has slight high blood pressure that is being treated with a low-sodium diet. An EKG done in the ER to rule out a myocardial infarction shows that the heart is working normally, but the symptoms are still there. A deeper look into his past shows that he sometimes feels anxious, wants to leave wherever he is, and uses ETOH to deal with fears at work.
The above symptoms give the sense of anxiety, which leads to the following steps to check the health. On the Hamilton Anxiety Rating Scale (HAM-A), a score of 26 is found. The mental status test shows that the client is awake, has a good sense of where they are, and can speak clearly. He says he feels “blah,” and he is nervous even during the test. He says he doesn’t have visual or auditory hallucinations, doesn’t think in a paranoid way, and has pretty good reasoning. Generalized anxiety disorder is the most likely diagnosis based on the above symptoms. As we’ll talk about below, the main mental health nurse practitioner has a number of ways to help the patient get treated.
Decision #1: Start taking 50 mg of Zoloft every day At this point, the PMHNP can start Zoloft 50 mg orally once a day, Imipramine 25 mg orally twice a day, or Buspirone 10 mg orally twice a day. I chose to start taking 50 mg of Zoloft every day. Zoloft is a drug that belongs to a group of medicines called selective serotonin reuptake inhibitors (SSRI). These medicines are the first choice for treating anxiety conditions (Crocco et al., 2017). People with anxiety often have too little or too much serotonin, and Zoloft works to increase the amount of serotonin in the brain by stopping it from being taken back out. I chose this drug to start with because it has mild side effects, like sweating, sleeplessness, and loss of hunger.
The other two choices are to start Imipramine 25 mg by mouth twice a day or Buspirone 10 mg by mouth twice a day. I don’t want to choose either one because Imipramine is a tricyclic antidepressant that is mostly given to people who are nervous or depressed. Buspirone, on the other hand, is only used to treat anxiety when SSRIs don’t work (Thom et al., 2020). Also, Buspirone only helps relieve symptoms for a short time, while Zoloft can be used for long-term treatment.
First-line treatments for anxiousness are called selective serotonin reuptake inhibitors. By choosing Zoloft, it was thought that the symptoms might get better within four weeks. I wanted to get rid of fear and other signs of too much anxiety, like shortness of breath. I also thought the patient would be able to fall asleep, even though I knew Zoloft could sometimes make people unable to sleep. (Schneider, 2016) These choices should be based on moral principles like beneficence and non-maleficence. For example, choosing the right drug for treatment will keep the patient from getting hurt or having their situation get worse.
Second Choice: Raise the amount to 75mg PO once a day After the first treatment decision of Zoloft 50mg PO was made, the patient came back and said that the tightness in his chest, shortness of breath, and worrying at work had gotten better. The HAM-A score has dropped to 18 in part. The other two choices are to either increase the dose of Zoloft to 100 mg PO once a day or not change the dose of Zoloft at this time. My choice is to up the dose of Zoloft to 75 mg PO once a day and reevaluate in four weeks. I’ve decided to up the dose because the patient is responding well to the drug and can handle the side effects well. The best thing to do is to slowly raise the dose because the HAM-A level has gone down, but not enough to be safe. (Strawn et al., 2018) A number of 18 means that the patient has moderate anxiety and that some of their symptoms are getting better. I think that if you up the dose, the symptoms will go away by more than 50%. The other two choices are to either increase the dose of Zoloft to 100 mg PO once a day or not change the dose of Zoloft at this time. I didn’t choose to up the dose to 100mg because it wouldn’t show a gradual increase in dose, which is what is suggested during treatment. Second, the high dose is suggested for people with very bad anxiety or when smaller doses don’t work. The other choice is to not change the dose of the drug, which I think will make the treatment last longer and make it harder to reach the goals (Crocco et al., 2017). With a HAM-A score of 18, it is suggested to increase the dose to help relieve symptoms even more. By deciding to raise the dose of Zoloft to 75mg, I expect the patient to report that his or her symptoms are getting better. As the symptoms get better, the HMA-A sore should get better, too. I think the patient will have some mild side effects, like trouble sleeping and feeling tired. I know that I should make a choice that is good for the patient when I have to decide between these options. For example, if you decide to raise the amount to 100 mg, the side effects will hurt the patient. If you don’t change the dose, it will take the patient longer to get better, which is a sign of neglect.
#3: Don’t change the present dose The patient’s symptoms got even better after the earlier dose of Zoloft was raised to 75mg. The HMA-A score has gone down to 10, which means that symptoms have gone down by 61%. The choices are to keep the current amount of Zoloft at 75mg, increase it to 100mg, or add Buspirone to it. I’ve decided to keep taking 75 mg of Zoloft once a day for the next month. Because the client’s symptoms have gone down by more than 50%, it is clear that the drug and dose are working well. The patient can also deal with the side effects, which shows that the current treatment is right for him or her. I didn’t choose to increase the dose of Zoloft to 100mg because the patient is doing well with the current treatment and increasing the dose will only cause bad side effects (Lewis et al., 2019). The other option is to add Buspirone, which I don’t think is required because adding or switching drugs is only recommended when the first line of treatment isn’t working well. Keeping the amount at 75mg for the next month will definitely make the symptoms go away even more. I want to completely get rid of signs like fear, a fast heart rate, and trouble sleeping. I also want to get the HMA-A score down to less than 10, which will show a big drop in worry. At this point, ethical considerations include making the best decisions for the patient to show beneficence and telling the patient about the possible side effects of increasing the dose and augmentation (Schneider, 2016).
Conclusion The main diagnosis for the patient is a generalized anxiety condition, which is shown by fear, insomnia, a faster heart rate, and a feeling that bad things are about to happen. Based on what I’ve learned, I think Zoloft is the best way to treat the patient’s situation. The drug is an SSRI. Lewis et al. (2019) say that it should be the first choice for treating nervousness. Imipramine and Buspirone are also options, but they are used only as a second choice when SSRIs don’t work as well as planned. After four weeks of treatment with Zoloft 50mg, the patient has fewer anxious symptoms and a HAM-A score of 18. At this point, I know that the patient is doing well and that a small increase in the amount of Zoloft will make things even better. I chose to raise the dose to 75mg instead of 100mg so that I could handle the side effects better. At some point, the patient returns with a much better HMA-A score and fewer complaints. The best way to control anxiety feelings for the next month is to keep the dose at 75 mg.
Crocco, E. A., Jaramillo, S., Cruz-Ortiz, C., & Camfield, K. (2017). Pharmacological management of anxiety disorders in the elderly. Current treatment options in psychiatry, 4(1), 33-46. DOIhttps://doi.org/10.1007/s40501-017-0102-4
Lewis, G., Duffy, L., Ades, A., Amos, R., Araya, R., Brabyn, S., … & Lewis, G. (2019). The clinical effectiveness of sertraline in primary care and the role of depression severity and duration (PANDA): a pragmatic, double-blind, placebo-controlled randomised trial. The Lancet Psychiatry, 6(11), 903-914. https://doi.org/10.1016/S2215-0366(19)30366-9
Schneider, M. R. (2016). Clinical and Social Contexts of Ethical Issues in Mental Health Care. AMA Journal of Ethics, 18(6), 567-571. https://journalofethics.ama-assn.org/article/clinical-and-social-contexts-ethical-issues-mental-health-care/2016-06
Strawn JR, Geracioti L, Rajdev N, Clemenza K, Levine A. Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert Opin Pharmacother. 2018;19(10):1057-1070. doi: 10.1080/14656566.2018.1491966
Thom, R. P., Keary, C. J., Waxler, J. L., Pober, B. R., & McDougle, C. J. (2020). Buspirone for the Treatment of Generalized Anxiety Disorder in Williams Syndrome: A Case Series. Journal of Autism and Developmental Disorders, 50(2), 676-682. DOI: 10.1007/s10803-019-04301-9
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