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
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)
Increase dose to 20mg po daily
Result 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)
Result of decision three
Maintained dose
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, Please follow the rubric
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Name: NURS_6630_Week6_Assignment_Rubric
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Grid View
·
List View
|
Excellent |
Good |
Fair |
Poor |
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Introduction to the case (1 page) |
9 (9%) – 10 (10%) The response accurately, clearly, and fully summarizes in detail the case for the Assignment. |
8 (8%) – 8 (8%) The response accurately summarizes the case for the Assignment. |
7 (7%) – 7 (7%) The response inaccurately or vaguely summarizes the case for the Assignment. |
0 (0%) – 6 (6%) The response inaccurately and vaguely summarizes the case for the Assignment, or is missing. |
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|
Decision #1 (1–2 pages) |
18 (18%) – 20 (20%) The response accurately and clearly explains in detail the decision selected. |
16 (16%) – 17 (17%) The response accurately explains the decision selected. |
14 (14%) – 15 (15%) The response inaccurately or vaguely explains the decision selected. |
0 (0%) – 13 (13%) The response inaccurately and vaguely explains the decision selected. |
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|
Decision #2 (1–2 pages) |
0 (0%) – 13 (13%)
The response inaccurately and vaguely explains in detail the decision selected. |
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|
Decision #3 (1–2 pages) |
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|
Conclusion (1 page) |
14 (14%) – 15 (15%)
The response accurately and clearly summarizes in detail the recommendations on the treatment options selected for this patient. |
12 (12%) – 13 (13%) The response accurately summarizes the recommendations on the treatment options selected for this patient. |
11 (11%) – 11 (11%) The response inaccurately or vaguely summarizes the recommendations on the treatment options selected for this patient. |
0 (0%) – 10 (10%) The response inaccurately and vaguely summarizes the recommendations on the treatment options selected for this patient, or is missing. |
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|
Written Expression and Formatting – Paragraph Development and Organization: |
5 (5%) – 5 (5%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity. |
4 (4%) – 4 (4%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. |
3.5 (3.5%) – 3.5 (3.5%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. |
0 (0%) – 3 (3%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided. |
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|
Written Expression and Formatting – English writing standards: |
5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors. |
4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors. |
3.5 (3.5%) – 3.5 (3.5%)
Contains several (3 or 4) grammar, spelling, and punctuation errors. |
0 (0%) – 3 (3%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. |
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|
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list. |
5 (5%) – 5 (5%)
Uses correct APA format with no errors. |
4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors. |
3.5 (3.5%) – 3.5 (3.5%)
Contains several (3 or 4) APA format errors. |
0 (0%) – 3 (3%)
Contains many (≥ 5) APA format errors. |
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|
Total Points: 100 |
Name: NURS_6630_Week6_Assignment_Rubric
Exit
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
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)
Increase dose to 20mg po daily
Result 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)
Result of decision three
Maintained dose
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.
Begin Imipramine 25mg po daily
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
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.
Discontinue Tofranil and begin SSRI
Guidance to Student
At this point, it is important that you discontinue the Tofranil due to the client’s bundle branch block. Recall that Tofranil can cause orthostatic hypotension, sudden death, arrhythmias, tachycardia, and QTc prolongation. It should not be used in clients who have already been identified as having an abnormality of cardiac conduction.
The most appropriate course of action for you to take would be the discontinuation of Tofranil and the initiation of an SSRI, such as Paxil (paroxetine) or Zoloft (sertraline), as these are considered first-line agents for the treatment of generalized anxiety disorders. Tofranil is considered a second-line agent.
BuSpar is also considered a second-line agent. It may have a role to play in the care of this client but not until an adequate trial of a first-line agent has been undertaken.
If imipramine 25 mg is maintained
RESULTS OF DECISION POINT TWO
· Client returns to clinic in four weeks
· Client reports that he has had no change in his level of anxiety
· Client reports that his anxiety may be getting a bit “worse” because he has been having the strange bouts of dizziness
OR
Begin Buspirone 10mg po 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
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
Increase buspirone to 20 mg orally TID
RESULTS OF DECISION POINT TWO
· Client returns to clinic in four weeks
· Client reports nausea, dizziness, nervousness, headaches, and dry mouth
· HAM-A score reveals no change and he reports that he still feels anxious
Please, Please follow the rubric
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Name: NURS_6630_Week6_Assignment_Rubric
·
Grid View
·
List View
|
Excellent |
Good |
Fair |
Poor |
|||||||
|
Introduction to the case (1 page) |
9 (9%) – 10 (10%) The response accurately, clearly, and fully summarizes in detail the case for the Assignment. |
8 (8%) – 8 (8%) The response accurately summarizes the case for the Assignment. |
7 (7%) – 7 (7%) The response inaccurately or vaguely summarizes the case for the Assignment. |
0 (0%) – 6 (6%) The response inaccurately and vaguely summarizes the case for the Assignment, or is missing. |
||||||
|
Decision #1 (1–2 pages) |
18 (18%) – 20 (20%) The response accurately and clearly explains in detail the decision selected. |
16 (16%) – 17 (17%) The response accurately explains the decision selected. |
14 (14%) – 15 (15%) The response inaccurately or vaguely explains the decision selected. |
0 (0%) – 13 (13%) The response inaccurately and vaguely explains the decision selected. |
||||||
|
Decision #2 (1–2 pages) |
0 (0%) – 13 (13%)
The response inaccurately and vaguely explains in detail the decision selected. |
|||||||||
|
Decision #3 (1–2 pages) |
||||||||||
|
Conclusion (1 page) |
14 (14%) – 15 (15%)
The response accurately and clearly summarizes in detail the recommendations on the treatment options selected for this patient. |
12 (12%) – 13 (13%) The response accurately summarizes the recommendations on the treatment options selected for this patient. |
11 (11%) – 11 (11%) The response inaccurately or vaguely summarizes the recommendations on the treatment options selected for this patient. |
0 (0%) – 10 (10%) The response inaccurately and vaguely summarizes the recommendations on the treatment options selected for this patient, or is missing. |
||||||
|
Written Expression and Formatting – Paragraph Development and Organization: |
5 (5%) – 5 (5%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity. |
4 (4%) – 4 (4%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. |
3.5 (3.5%) – 3.5 (3.5%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. |
0 (0%) – 3 (3%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided. |
||||||
|
Written Expression and Formatting – English writing standards: |
5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors. |
4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors. |
3.5 (3.5%) – 3.5 (3.5%)
Contains several (3 or 4) grammar, spelling, and punctuation errors. |
0 (0%) – 3 (3%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. |
||||||
|
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list. |
5 (5%) – 5 (5%)
Uses correct APA format with no errors. |
4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors. |
3.5 (3.5%) – 3.5 (3.5%)
Contains several (3 or 4) APA format errors. |
0 (0%) – 3 (3%)
Contains many (≥ 5) APA format errors. |
||||||
|
Total Points: 100 |
Name: NURS_6630_Week6_Assignment_Rubric
Exit
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