Examine Case Study: Pakistani Woman with Delusional Thought Processes. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
At each decision point stop to complete the following:
- Decision #1
- Which decision did you select?
- Why did you select this decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
- Decision #2
- Why did you select this decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
- Decision #3
- Why did you select this decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
- SAMPLE ONLY
NURS 6630
WEEK SEVEN
Case 2: Volume 2, Case #11: The figment of a man who looked upon the lady
Introduction
Briefly, this is a scenario of a 42 year- old woman with a complex psychiatric history extending from depression, posttraumatic stress disorder, insomnia, visual hallucinations (little man)and impaired behavior with aggression. In the course of more than 36 months, the client was treated with Paroxetine (SSRI), Bupropion ( NDRI), Tiagabine, Ramelteon and , but finally a combination of Lexapro, Bupropion and quetiapine was able to decrease her symptoms . The client’s medical history includes diabetes, hypertension, CAD, hyperlipidemia, COPD, OSA, GERD, Glaucoma, overweight and a remote history of substance abuse.
Related Professional Questions
Certain medications or supplements can cause symptoms of mental illness and also due to her extensive medical history and usage of multiple medications I would ask the following questions:
1. Do you take any over -the – counter, herbal supplements or remedies and I would check for interactions with current medication regimen?
2. When and how often do you use your albuterol inhaler ? Some of the side effects of albuterol include anxiety, nervousness, and insomnia ( Cunha, 2016)
Sleep Hygiene: Do you keep regular sleep schedule ? Do you drink caffeine beverages close to bedtime?
Patient History
The patient may not be a reliable source of information, particularly that she has a significant mental illness that affects her functioning, hence verifying her responses with her direct family members, and mental social workers to get clues to the underlying or precipitating causes of mental crisis. Also checking facility records from previous encounters, or any psychiatric hospitalizations would be useful.
Diagnostics Testing
1. Thyroid Stimulating Hormone (TSH). Based on recent evidence, the prevalence of depressive symptoms in hypothyroidism was nearly 50%, and clinical depression occurs in more than 40% of people suffering from hypothyroidism ( Bhagwat, 2017)
2. Electrocardiogram (ECG) The client has cardiovascular diseases ( HTN, CAD), with risks of cardio complications. In the setting of taking antidepressants and antipsychotics, baseline ECG and possibly every three to six months would be appropriate. Several atypical antipsychotics including quetiapine (Seroquel) are known to cause prolongation of the QT interval, hypothesized to occur via direct inhibition of the cardiac delayed potassium rectifier channel, which extends the ventricular repolarization process (Zhai et al., 2017)
Differential Diagnoses
1. Posttraumatic Stress Disorder ( PTSD)_
2. Major Depressive Disorder (MDD)
3. Insomnia Disorder.
Pharmacotherapy Options for Sleep/ Wake cycle
1. Zolpidem (Ambien) 5mg oral at bedtime for Seven days.
Zolpidem is nonbenzodiazepine hypnotic, it works by enhancing GABA inhibitory actions that provide sedative hypnotic effects more selectively than other actions of GABA (Stahl, 2017). With its side effects of sedation, low dose prescribed as the client has respiratory problems (sleep apnea OSA)). Studies have shown that Zolpidem did not significantly worsen OSA as measured by the numbers and duration of pauses in breathing during sleep, but in one trial, it significantly lowered minimum oxygen levels during the night when compared with placebo ( Mason & Smith, 2015).
2. Trazadone 25 mg oral at bedtime for Thirty days.
Trazadone is a serotonin 2 antagonist/reuptake inhibitor, used in management of depression and insomnia. It is absorbed well, metabolized by CYP 450 3A4 with average half life of 6hrs. It has less side sedative effects compared to zolpidem (Stahl, 2017)
The best choice for the client would be Trazadone as there is no reliable evidence of dependence or withdraws and it can also work for the client’s depression.
Conclusion
The case was a perfect example how it is sometimes difficult to find effective pharmacological treatments of psychiatric illnesses. In the course of four years, the client was prescribed 5-6 medications targeting different neurotransmitters to improve the symptoms. Client’s polypharmacy increased risks of drug-drug interactions, and her medical comorbidities increased risks of adverse reactions. Lesson learned from this study was that treatment should be optimally initiated after diagnosis, and augment or switching to a new agent must be carefully done in consideration of possible side effects and better outcomes.
References
Bhagwat, N., Tayde, P., Sharma, P., Sharma, B., Dalwadi, P., Sonawane, A., … Varthakavi, P. (2017). Hypothyroidism and depression: Are cytokines the link? Indian Journal of Endocrinology and Metabolism, 21(6), 886. Retrieved from https://web-b-ebscohost-com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=7&sid=aeb79c1d-68dc-40a4-bd10-f956796bc9e8%40sessionmgr101
Cunha, J. (2016). Common Side Effects of Ventolin HFA (Albuterol Sulfate Inhalation Aerosol) Drug Center – RxList. Retrieved from https://www.rxlist.com/ventolin-hfa-side-effects-drug-center.htm
Mason, M., & Smith, I. (2015). Effects of opioid, hypnotic and sedating medications on obstructive sleep apnoea (OSA) in adults with known OSA | Cochrane. Retrieved from http://www.cochrane.org/CD011090/AIRWAYS_effects-opioid-hypnotic-and-sedating-medications-obstructive-sleep-apnoea-osa-adults-known-osa
Zhai, D., Lang, Y., Dong, G., Liu, Y., Wang, X., Zhou, D., … Zhang, R. (2017). QTc interval lengthening in first-episode schizophrenia (FES) patients in the earliest stages of antipsychotic treatment. Schizophrenia Research, 179, 70-74. Retrieved from https://resolver-ebscohost-com.ezp.waldenulibrary.org/openurl?ID=pmid%3a27727006&genre=article&atitle=QTc+interval+lengthening+in+first-episode+schizophrenia+(FES)+patien
