BACKGROUND Clinical decision-making (CDM) exercises are used to help the student make sense of data gathered, from oftentimes multiple sources, that help one to draw a conclusion about the information, as it applies to the patient. In a simulated environment, CDMs can still have an impact student learning through case studies, and decisions made about the diagnosis, treatment, and management. The PMHNP program utilizes CDMs to assist students in assessing, synthesizing, organizing, diagnosing, and managing patients through case studies in a safe environment for students to learn. INSTRUCTIONS In a Word document, inclusive of a title page, provide answers to the questions contained in this CDM about Nancy. There are 9 questions that include assessment, diagnosis, treatment, and a final question to collect references used as you craft your answers. Be sure to include the question (but not the scenario information), as you are writing your responses, so it is easier to track and ensures accuracy in grading. As you are answering questions, be sure to maintain APA formatting style, including references and pagination. Resources for APA formatting can be found in the Class Tools module in Canvas. This assignment uses the Universitys plagiarism software, UniCheck, so please be sure to double check that you are paraphrasing information and providing information that is synthesized from your readings. You will only have 1 attempt to upload the document. A rubric is provided for your review. Please be sure to familiarize yourself with the rubric prior to submission of your work. Additional Information Recommended sources for this CDM include textbooks already in use in this program such as Sadock et al. (2017), DSM-5 Manual (2013), Stahl Prescribers Guide (2020), Zimmerman, articles, and treatment guidelines (APA and the VA, etc.). Question 1 (8 points) Nancy, a 26-year-old female, was evaluated by your co-worker three weeks ago. After Nancy’s evaluation, she was referred and admitted to a partial hospitalization program (PHP) due to the severity of her mood symptoms. On initial evaluation, she presented with symptoms mania and delusions. The complete working diagnosis list is as follows: Bipolar I Disorder, Current/MRE Manic, Severe, with Psychosis Relationship Distress with Spouse or Intimate Partner Other Problem Related to Employment The admitting PHP psychiatrist agreed with your working diagnosis as listed above. From the information you have so far, name one differential and one rule out diagnosis and give a brief explanation why you chose those (2 points each/4 points total) What questions will you ask to confirm the differential or the rule out you listed in #1? List ten questions for each diagnosis that will help you to make the above distinction. Hint: The questions you choose must rule out the diagnosis, consider which are most pertinent (2 points each/4 points total) Question 2 (7 points) After one week in the PHP, Nancy transitioned to the intensive outpatient program (IOP) where she attended group therapy 3 times per week. Nancy has now completed 2 weeks of IOP. She was last seen by the PMHNP in the program 7 days ago and given her last prescription of Zyprexa (olanzapine)15 mg PO nightly. Today, she has a follow up appointment with you, the co-worker who originally evaluated Nancy is on vacation. Nancy reports less mood fluctuations, sleeping 9 hours per night, and denies symptoms of mania. There are no signs of psychosis. In fact, Nancys husband reports that most of the symptoms subsided a week after starting the olanzapine. In considering Nancys primary psychiatric diagnoses of Bipolar Disorder and manic symptoms on initial assessment, what is your major concern at this time regarding her mood symptoms? (3 points) What questions do you need to ask her about this concern? List 8 of the pertinent questions to address this concern as if you are talking directing to Nancy. (4 points) Question 3 (12 points) Nancy is concerned that she is sleeping too much, has started to feel a little down, and misses her manic mood. She rates her mood as 30/100, with 0 being most depressed. She is worried that being a little down now will later result in depression, that she will end up suicidal, and that she may have to be hospitalized again. Nancy tells you that she is attending therapy, although she really doesn’t see the benefit in doing so. What is the risk of suicide during a bipolar depression episode? Provide detailed evidence-based support. (4 points) What might you say to Nancy to help motivate her participation in Social Rhythm Therapy (SRT)? Use evidence-based support for treatment in bipolar. (4 points) List 4 goals of SRT in the treatment of bipolar disorder. Describe how each will help Nancy. (4 points) Question 4 (14 points) Nancy tells you that she is open to continuing therapy and plans to be more involved when she attends meetings. She and her spouse are still sexually active and are working on their marriage. She is hopeful that therapy may help her in her marriage as well. She denies taking any other medications with the exception of a multivitamin daily. Her appetite has improved. She says she is eating all the time, although she admits that this is mostly carbs, sweets, and the eating has increased at night. She has gained twelve pounds since her last appointment three weeks ago. LMP was 6 weeks ago, it has been irregular at times. Her vital signs are as follow: T 98, P 76, RR 16, BP 108/62. Her BMI is . Based on the information provided, discuss concerns you have with Nancys current medication regimen other than those listed above. (2 points) Discuss the known side effects olanzapine has on appetite/weight, lipids, and glucose. (3 points) Discuss your plan for monitoring for these side effects, including which labs you will monitor and how often you will monitor. (3 points) List two atypical antipsychotic medications that you could use, in lieu of olanzapine, should metabolic problems and weight gain warrant changing medications. (1 point each/2 points total) What is the evidence-based support for your choices? In detail, what does the reference say about the use of these particular medications in the treatment of bipolar? (2 points each/4 points total) Question 5 (9 points) While discussing the plan of care for recent changes in mood and sleep, Nancy requests a prescription for Xanax (alprazolam). She states that this worked well in the past. You inquire about past use as this medication is not documented in the medication history. Nancy responds, “it was the only thing that made me feel better, I got them from my husband.” She reports using her husband’s prescription of alprazolam and also had a couple glasses of wine to help “boost the effect.” 1. What questions will you ask regarding substance use? Ask these questions to Nancy as if you are in an actual interview. Ask all questions needed to determine if she meets criteria for any substance use disorder; however, do not list questions in a paragraph form, use bullet points format only (5 points) What is your response to Nancy about her current use of alprazolam? (2 points) How will you educate about concurrent use of benzodiazepines and alcohol? (2 points) Question 6 (11 points) Nancy reports that she used her husbands medications on two occasions in the past week only, each time she took 2 tablets of alprazolam mg to help with sleep. She denies the use of any illicit substance or any other prescription not prescribed to her. She reports alcohol use on those same two occasions and denies other use of alcohol because” I don’t like the way it makes me feel, it makes me groggy the next morning. ” Nancy tells you that she wants to continue with olanzapine, it has certainly helped with her manic and psychotic symptoms. She then tells you that her sister takes Lexapro (escitalopram), and she would like to add that to the olanzapine. What is the evidence about the use of antidepressants in bipolar? Provide thorough details with references no less than 5 years old. (3 points) Will you start her on an antidepressant at this time? (2 points) How will you respond to Nancy? Write your answer as if you are talking directly to Nancy. (3 points) Discuss the FDA approved indications for olanzapine and whether or not this medication could provide stabilization for acute depression in Bipolar Disorder. (3 points) Question 7 (12 points) You have decided to avoid starting an antidepressant; now consider an alternative medication to stabilize her mood. List one medication you would consider adding to the olanzapine. (2 pts) List 3 pros of treating bipolar depression with this medication (3 pts) List 3 cons of treating bipolar depression with this medication (3 pts) Cite at least one recent evidence-based literature to support the use of this medication for this disorder. Provide details. (4 pts) Question 8 (8 points) Despite all the potential side effects of each medication, you decide to keep Nancy on olanzapine 15 mg 1 tablet by mouth at bedtime and have decided to add Lamictal (lamotrigine). Discuss the mechanism of action of lamotrigine. (3 pts) What are five major teaching points you will need to discuss when starting lamotrigine? ( pts) What will you need to consider given Nancys history and the fact that she is still of childbearing age and able to get pregnant? ( pts) Question 9 (14 points) You are now ready to discuss the plan of care with Nancy and educate her. Write a prescription for olanzapine and lamotrigine. Include all elements of a prescription. (5 points total) For future reference, how is each medication titrated up if necessary, on a follow up visit? (3 points total) How will you explain the expectations of the medication to Nancy? Hint- what are the target symptoms, when to expect efficacy, etc.(2 points each) What are the side effects of the medications? (2 points each) Discuss the risk of lamotrigine to the fetus if taken during pregnancy. (1 point) When will you ask Nancy to follow up?
