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

RESOURCES

Hamilton, M. (1959). Hamilton Anxiety Rating Scale. Psyctests,

doi:10.1037/t02824-0

Decision pointe 2

At last visit you give Zoloft

• 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)

What would you do?

A. Would you increase the Zoloft to 75mg 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)

B. Or Would you begin Tofranil (imipramine) 100 mg orally BID

• RESULTS OF DECISION POINT TWO
  • Client returns to clinic in four weeks
  • Client is a bit evasive about his symptoms. Eventually he admits that he stopped taking the medication about a week ago because he was experiencing difficulty acquiring an erection.

C. Or Would you maintain the dose

• Client returns to clinic in four weeks
• Client reports no further decreases in anxiety and is wondering if this means that the medication will not be effective for him

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• 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