ntroduction 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.

Decision Point One

Start Zyprexa (olanzapine) 10 mg orally at BEDTIME 

RESULTS OF DECISION POINT ONE

·   Client returns to clinic in four weeks

·   Her PANSS decreases to a partial response (decrease in positive symptoms by 25%)

·   She comes in today with a reported weight gain of 5 pounds. When questioned further on this point, she states that she can never seem to get full from her meals, so she is snacking constantly throughout the day 

Decision Point Two

Change medication to Geodon (ziprasidone) 40 mg orally BID with meals

RESULTS OF DECISION POINT TWO

·   Client returns to clinic in four weeks

·   Client has a significant reduction in her PANSS (reduction of 40% in positive symptoms) 

·   She notices her weight is down slightly from the previous visit (2 pounds) and that her hunger has been curbed since starting this med

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·  BACKGROUND

·  The client is a 34-year-old Pakistani female who moved to the United States in her late teens/early 20s. She is currently in an “arranged” marriage (her husband was selected for her when she was 9 years old). She presents following a 21-day hospitalization for what was diagnosed as “brief psychotic disorder.” She was given this diagnosis as her symptoms have persisted for less than 1 month. 

·  Prior to admission, she was reporting visions of Allah, and over the course of a week, she believed that she was the prophet Mohammad. She believed that she would deliver the world from sin. Her husband became concerned about her behavior to the point that he was afraid of leaving their 4 children with her. One evening, she was “out of control,” which resulted in his calling the police and her subsequent admission to an inpatient psych unit.

·  During today’s assessment, she appears quite calm and insists that the entire incident was “blown out of proportion.” She denies that she believed herself to be the prophet Mohammad and states that her husband was just out to get her because he never loved her and wanted an “American wife” instead of her. She says she knows this because the television is telling her so. 

·  She currently weighs 140 lbs., and she is 5’ 5.

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·  SUBJECTIVE

·  Client reports that her mood is “good.” She denies auditory/visual hallucinations but believes that the television talks to her. She believes that Allah sends her messages through the TV. At times throughout the clinical interview, she becomes hostile towards you but then calms down.

·  A review of her hospital records shows that she received a medical workup from physician, who reported her to be in overall good health. Lab studies were all within normal limits. 

·  Client admits that she stopped taking her Risperdal about a week after she got out of the hospital because she thinks her husband is going to poison her so that he can marry an American woman. 

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·  MENTAL STATUS EXAM

·  The client is alert and oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Her speech is slow and, at times, interrupted by periods of silence. Self-reported mood is euthymic. Affect is constricted. Although the client denies visual or auditory hallucinations, she appears to be “listening” to something. Delusional and paranoid thought processes as described above. Insight and judgment are impaired. She is currently denying suicidal or homicidal ideation.

·  You administer the PANSS which reveals the following scores:

·  -40 for the positive symptoms scale

·  -20 for the negative symptom scale

·  -60 for general psychopathology scale

·  Diagnosis: Schizophrenia, paranoid type

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·  RESOURCES

·  PANSS Scale. Available at: http://egret.psychol.cam.ac.uk/medicine/scales/PANSS 

·  § Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261–276. doi:10.1093/schbul/13.2.261

· https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf 

·  § Clozapine REMS Program. (n.d.). Clozapine REMS: A guide for healthcare providers. Retrieved September 7, 2016, from https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf

·  http://www.ima.org.il/FilesUpload/IMAJ/0/40/20149.pdf

·  § Paz, Z., Nalls, M., and Ziv, E. (2011). The genetics of benign neutropenia. Israel Medical Association Journal, 13(10), 625–629. Retrieved from http://www.ima.org.il/FilesUpload/IMAJ/0/40/20149.pdf 

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·   She does complain that it is difficult to remember the second dose and admits to missing afternoon doses on several occasions over the past month 

Decision Point Three

Give the client a few test doses of Risperdal 1 mg orally BID for 3 days to see if she tolerates the medication. If tolerated, start Invega Sustenna at an appropriate starting and maintenance dose

Guidance to Student

Changing to Risperdal oral therapy to test for side effects and then switching to Invega Sustenna is a good option in a client who has problems with compliance and who shows good effect from oral therapy. The manufacturer advertises that clients can be switched from an entirely different medication to Invega Sustenna if tolerability can be shown through oral therapy. From a clinical standpoint, the client may or may not respond to the medication and therefore could be wasted time. Remember, manufacturers have a product to sell, and their information should always be verified before implementing in clinical practice. 

Although Geodon is recommended twice daily with meals, some providers will choose to give the dose once a day and monitor for efficacy in clients who have compliance issues with BID dosing regimens.

Latuda is a medication that behaves much like Geodon and is therefore a good option for someone who responds to Geodon but has compliance problems due to its once daily dosing schedule. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting, and extrapyramidal side effects can be problematic and therefore good counseling points for clients. Clients usually tolerate lower doses (40 mg), but significant GI distress and movement disorders can occur when doses are pushed upward toward the daily max of 160 mg.