E‌‍‍‍‌‍‍‌‌‍‍‍‌‍‍‍‍‌‍‍xamine Case Study: An Asian American Woman. Diagnosis-Bipol

E‌‍‍‍‌‍‍‌‌‍‍‍‌‍‍‍‍‌‍‍xamine Case Study: An Asian American Woman. Diagnosis-Bipolar Disorder. You will be asked to 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. At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature. 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 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 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 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 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. BACKGROUND INFORMATION The client is a 26-year-old woman of Korean descent who presents to her first appointment following a 21-day hospitalization for onset of acute mania. She was diagnosed with bipolar I disorder. Upon arrival in your office, she is quite “busy,” playing with things on your desk and shifting from side to side in her chair. She informs you that “they said I was bipolar, I don’t believe that, do you? I just like to talk, and dance, and sing. Did I tell you that I liked to cook?” She weights 110 lbs. and is 5’ 5” SUBJECTIVE Patient reports “fantastic” mood. Reports that she sleeps about 5 hours/night to which she adds “I hate sleep, it’s no fun.” You reviewed her hospital records and find ‌‍‍‍‌‍‍‌‌‍‍‍‌‍‍‍‍‌‍‍that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits. You find that the patient had genetic testing in the hospital (specifically GeneSight testing) as none of the medications that they were treating her with seemed to work. Genetic testing reveals that she is positive for CYP2D6*10 allele. Patient did well enough on Lithium to be discharged from the hospital but admits she has not been taking it as prescribed. When further questioned on the subject, she provides no additional details. MENTAL STATUS EXAM The patient is alert, oriented to person, place, time, and event. She is dressed quite oddly- wearing what appears to be an evening gown to her appointment. Speech is rapid, pressured, tangential. Self-reported mood is euthymic. Affect broad. Patient denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, but insight is clearly impaired. She is currently denying suicidal or homicidal ideation. The Young Mania Rating Scale (YMRS) score is 22 RESOURCES § Chen, R., Wang, H., Shi, J., Shen, K., & Hu, P. (2015). Cytochrome P450 2D6 genotype affects the pharmacokinetics of controlled-release paroxetine in healthy Chinese subjects: comparison of traditional phenotype and activity score systems. European Journal of Clinical Pharmacology, 71(7), 835-841. doi: Decision Point One Select what the PMHNP should do: Begin Lithium 300 mg orally BID Begin Risperdal 1 mg orally BID Begin Seroquel XR 300 mg orally at HS Decision Point One Begin Lithium 300 mg orally BID RESULTS OF DECISION POINT ONE Client returns to clinic in four weeks Client informs the PMHNP that she has been taking her drug “off and on” only when she “feels like she needs it” Today’s presentation is similar to the first day you met her Decision Point Two Increase Lithium to 450 mg orally BID RESULTS OF DECISION POINT TWO Client returns to clinic in four weeks Client returns reports that she is still taking the medication when she feels that she needs it She remains quite manic and reports that her family is getting really upset because she likes to play her new guitar at night Decision Point One Begin Risperdal 1 mg orally BID RESULTS OF DECISION POINT ONE Client returns to clinic in four weeks Client is accompanied today by her mother who must help the client into your office, the client looks very sedated and lethargic Client’s mother explains that “she has been like this since about a week after the last office visit” Decision Point Two Change Risperdal to 2 mg at HS RESULTS OF DECISION POINT TWO Client returns to clinic in four weeks Client’s mother accompanies client again to today’s appointment and states “I think she’s getting worse, that medication is no good- look at her!” Client remains quite sedate and lethargic Decision Point One Begin Seroquel XR 300 mg orally at HS RESULTS OF DECISION POINT ONE Client returns to clinic in four weeks Client is reporting that she sleeps a bit more at bedtime Client states that she has gained about 2 or 3 pounds, which she does not like Client also reports that she has been constipated since starting this medication Client is also complaining of dry mouth which she does not like. Client’s score on the Young Mania Rating Scale has decreased from a 22 to an 18 Client is reporting really good mood, but is asking for a different medication because of the weight gain Decision Point Two Increase Seroquel XR to 400 mg orally at HS RESULTS OF DECISION POINT TWO Client returns to clinic in four weeks Client reports that her constipation is worse and that she has now gained a total of 7 pounds since starting this drug Client feels that you are not listening to her concerns and is very upset Client’s ‌‍‍‍‌‍‍‌‌‍‍‍‌‍‍‍‍‌‍‍Young Mania Rating Scale has decreased from 18 to 14

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