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BACKGROUND The client is a 34-year-old Pakistani female who moved to the United

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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.
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.
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
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
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
Decreased zyprexa to 7.5 mg orally at bed time
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Result of next decision (what happened): Client worsens (her positive symtpoms scale increased by 25% and her negative symptom scale score decreased by 10% indicating improved negative symptoms), but her weight becomes stabilized and excessive hunger abates
Husband explains that she is becoming less manageable at home, and he has to take time off from work because he is fearful of leaving her alone
Increase zyperxa to 10 mg orally at bed time
Guidance to Student
Weight gain is a significant problem with Zyprexa. Next to Clozaril (clozapine), Zyprexa causes the most weight gain of all the atypical antipsychotics. This is a side effect that a significant number of clients will experience. There also appears to be an increased association of newly diagnosed diabetes mellitus in clients treated with Zyprexa. Although this can be disease related in this population, Zyprexa is above what would be considered coincidental.
Risperdal is a good option, although it is dosed twice daily and compliance in this population can be problematic. There is evidence that shows giving Risperdal all at once can be efficacious and therefore could be an option down the road should compliance become an issue. Weight gain is also possible with Risperdal, but it is not as great as that seen with Zyprexa. If compliance does become an issue with this client, Risperdal has a long-acting injectable formulation, Risperdal Consta, that could be used. Remember, Risperdal Consta has to be given every 2 weeks at the provider’s office, and therapeutic blood levels take time to achieve (on average 3–6 weeks or 2–3 injections). Oral overlapping therapy is required to bridge this period of time. Another option in someone who responds to Risperdal would be Invega Sustenna (paliperidone palmitate), which is the first metabolite of Risperdal and has greater activity at the D2 receptor than Risperdal. An advantage of Invega Sustenna over Risperdal Consta is that therapeutic blood levels are attained within the first 4–7 days, and overlapping oral therapy is usually not necessary. A disadvantage is that during the initiating phase of medication, the first two doses need to be given within 4–7 days of one another. This is followed by monthly injections. There is another product on the market called Invega Trinza, which is given once every 3 months. This product is for clients who have been stabilized on Invega Sustenna for at least 4 months where the last two doses were the same strength (two months of 156 mg injections).
Increasing Zyprexa to 15 mg at bedtime will only worsen the weight gain side effect. While additional benefits from increasing the dose may be possible from an efficacy standpoint, side effects always need to be taken into consideration. “First, do no harm.” Qsymia is a weight loss medication that is a combination of phentermine and topiramate. It is only indicated to treat obesity. This client’s BMI (28.9 kg/M2) does not fit the definition of obesity (BMI >30 Kg/M2- Following from CDC website: Class 1: BMI of 30 to < 35, Class 2: BMI of 35 to < 40, Class 3: BMI of 40 or higher. Class 3 obesity is sometimes categorized as “extreme” or “severe” obesity). There are two things wrong with this therapy option. First, there are only a few occasions where add-on therapy to treat a side effect is acceptable, and weight gain is not one of those scenarios. Secondly, phentermine has a lot of cardiovascular toxicities (such as elevated BP, HR, and increased workload on the heart). if you choose abilify first Start Abilify (aripiprazole) 10 mg orally at BEDTIME RESULTS OF DECISION POINT ONE Client returns to clinic in four weeks Client returns and looks disheveled. Upon questioning, her husband states that she has not been sleeping at night. He states she is up and down all night. It has been disrupting his sleep too The client is unable to participate in the PANSS rating tool because she is continually nodding off (sleeping) during the appointment The appointment is not productive for assessing how she is responding to the Abilify started 4 weeks ago second chang abilify administration time to AM dose RESULTS OF DECISION POINT TWO Client arrives at office appearing to have slept better. Her husband tells you that she is still up and down at night, but it is much less frequently He notices that it is better when she takes her medication as soon as she awakens, but some days she forgets and takes it when she remembers (in the afternoon) Her PANNS has decreased by 5% since her initial visit Decision Point Three Select what the PMHNP should do next: Increase dose to 20 mg at bedtime and counsel client on the importance of taking this medication first thing in the morning due to akathisia and insomnia that can be problematic in some clients. Counsel the husband on setting up reminders for her at home to help avoid these symptoms at night. Submit an e-prescription to the client’s pharmacy for Ambien 10 mg orally at BEDTIME to help with sleep Psychopharmacologic Approaches to Treatment of Psychopathology Psychopharmacologic Approaches to Treatment of Psychopathology DC abilify and start latuda 40 mg orally daily Guidance to Student This is week 8 since therapy was initiated. Although the client’s side effects seem to be better managed, her PNSS is not changing by much. An acceptable time frame for treatment is defined as 4–6 weeks at an acceptable dose. Increasing Abilify to 20 mg in the morning certainly is an option, but she seems to be forgetful of taking this medication first thing in the morning on occasion and is still experiencing side effects when it is taken later in the day. It might be a good time to explore other options. Latuda is a medication that behaves much like Geodon (ziprasidone). It offers a once-daily dosing option and weight gain is minimal. She would not be expected to experience the insomnia and akathisia that has been experienced on the Abilify. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting, and extrapyramidal side effects can be problematic and therefore good counseling points to 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. Invega oral therapy is a good option as it has a once daily dosing option, and it has a greater effect at the D2 receptor than Abilify and may offer more efficacy and less insomnia and akathisia than seen in Abilify. It has a long-acting option that can be given monthly (to start). With good efficacy maintained over a 4-month period, it can be changed to once every 3 months. This is a good option in someone where compliance can be problematic. Depend on above medication trial need to answers on assignment questions Assignment: Assessing and Treating Patients With Psychosis and Schizophrenia Psychosis and schizophrenia greatly impact the brain’s normal processes, which interfere with the ability to think clearly. When symptoms of these disorders are uncontrolled, patients may struggle to function in daily life. However, patients often thrive when properly diagnosed and treated under the close supervision of a psychiatric mental health practitioner. For this Assignment, as you examine the patient case study in this week’s Learning Resources, consider how you might assess and treat patients presenting with psychosis and schizophrenia. To prepare for this Assignment: Review this week’s Learning Resources, including the Medication Resources indicated for this week. Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients with schizophrenia-related psychoses. The Assignment: 5 pages Examine Case Study: Pakistani Woman With Delusional Thought Processes. 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 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 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 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 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 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. Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.

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