Making a Medical Decision

BACKGROUND

Mrs. Maria Perez is a 53 year old Puerto Rican female who presents today due to a rather “embarrassing problem.”

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SUBJECTIVE

Mrs. Perez admits that she has had “problems” with alcohol since her father died in her late teens. She reports that she has struggled with alcohol since her 20’s and has been involved with Alcoholics Anonymous “on and off” for the past 25 years. She states that for the past 2 years, she has been having more and more difficulty maintaining her sobriety since the opening of the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during its grand opening at which point she was “hooked.” She states that she gets “such a high” when she is gambling. While gambling, she “enjoys a drink or two” to help calm her during high-stakes games. She states that this often gives way to more drinking and more reckless gambling. She also reports that her cigarette smoking has increased over the past 2 years and she is concerned about the negative effects of the cigarette smoking on her health.

She states that she attempts to abstain from drinking but she gets such a “high” from the act of gambling that she needs a few drinks to “even out.” She also notices that when she drinks, she doesn’t smoke “as much,” but she enjoys smoking when she is playing at the slot machines. She also reports that she has gained weight from drinking so much. She currently weights 122 lbs., which represents a 7 lb. weight gain from her usual 115 lb. weight.

Mrs. Perez is quite concerned today because she borrowed over $50,000 from her retirement account to pay off her gambling debts, and her husband does not know.

MENTAL STATUS EXAM

The client is a 53 year old Puerto Rican female who is alert and oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. Her speech is clear, coherent, and goal directed. Her eye contact is somewhat avoidant during the clinical interview. When you make eye contact with her, she looks away or looks down. She demonstrates no noteworthy mannerisms, gestures, or tics. Her self-reported mood is “sad.” Affect is appropriate to content of conversation and self-reported mood. She denies visual or auditory hallucinations, and no delusional or paranoid thought processes are readily appreciated. Insight and judgment are grossly intact; however, impulse control is impaired. She is currently denying suicidal or homicidal ideation.

Diagnosis: Gambling disorder, alcohol use disorder

MY DECISION:
DECISION 1:
Decision Point One

Vivitrol (naltrexone) injection, 380 mg intramuscularly in the gluteal region every 4 weeks
RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks
Mrs. Perez says she feels “wonderful” as she has not “touched a drop” of alcohol since receiving the injection
Client reports that she has not been going to the casino, as frequently, but when she does go she “drops a bundle” (meaning, spends a lot of money gambling)
Client She is also still smoking, which has her concerned. She is also reporting some problems with anxiety, which also has her concerned

OTHER DECISIONS NOT CHOSEN:
Antabuse (disulfiram) 250 mg orally every morning
RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks
Mrs. Perez reports to the office complaining of sedation, fatigue, and a “metallic taste” in her mouth, which “seems to be going away.” She also reports that she had just one drink about 5 days after starting the drug and thought that she would “die.” She reports that her face was red, and she felt that her heart would “pound right out of my chest.”
Mrs. Perez also reports that she continues to visit the casino but has not been spending as much money there. She has noticed that her cigarette smoking is increasing
AND:
Campral (acamprosate) 666 mg orally TID
RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks
Upon return Mrs. Perez states that she has noticed that she has been having suicidal ideation over the past week, and it seems to be getting worse
She is also reporting that she is having “out of control” anxiety

MY DECISION 2:
Decision Point Two

Add on Chantix (varenicline) 1 mg orally BID
RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Client reports that she had to stop taking Chantix secondary to abnormal dreams and agitation
She also reports that she felt nauseous and vomited several times after she began taking the drug

MY DECISION 3:
Decision Point Three

Discontinue Chantix and start Wellbutrin (bupropion) XL 150 mg orally daily
Guidance to Student
Mrs. Perez was experiencing normal side effects associated with Chantix. She should be counseled regarding the potential side effects associated with Chantix and reassured that they will most likely abate. It should be noted that the problem Mrs. Perez is experiencing from the Chantix is most likely related to the starting dose. Recall that this drug should be initiated at 0.5 mg/day; after 3 days, increase to 1 mg/day in two divided doses; after 4 days, the dose can be increased to 2 mg/day in two divided doses. Side effects would most likely have been minimized or completely avoided had she been started at the appropriate starting dose. Therefore, it may be prudent to restart this drug at 0.5 mg orally daily and uptitrate consistent with the manufacturer’s suggested titration schedule. It would not be appropriate to restart Mrs. Perez at 1 mg orally BID, as it would most likely result in a return of the unpleasant symptoms she experienced.

If Mrs. Perez is adverse to the idea of restarting Chantix, you could begin Wellbutrin XL, 150 mg orally daily.

Additionally, it should be noted that Mrs. Perez continues to engage in problematic gambling, at considerable personal financial cost. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling disorder and should also be encouraged to establish herself with a local chapter of Gamblers Anonymous.

RUBRIC:
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.
Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. For more information on Making a Medical Decision visit this: https://en.wikipedia.org/wiki/Medical_decision-making

Making a Medical Decision

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