Middle-Aged White Male with Anxiety 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. The PMHNP administers 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:10.1037/t02824-0 Decision Point One Begin Zoloft 50 mg orally 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 75 mg orally 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 Three Select what the PMHNP should do next: Increase Lexapro to 15 mg orally daily in AM Continue same dose of Lexapro but change administration time to bedtime Re-start BuSpar at 10 mg orally TID Guidance 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 trail 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. The PMHNP 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. At this point, nothing in the client presentation suggests the need to augment his Lexapro with any other agents. Therefore, buspirone augmentation would not be an appropriate response.

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