Question 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 a feeling of impending doom. He does have some mild hypertension (which is treated with a 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. The remainder of the physical exam was WNL. Assessing and Treating Patients with Anxiety Disorders Assessing and Treating Patients with Anxiety Disorders 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
Assessing and Treating Patients with Anxiety Disorders
The patient in the case is a middle-aged Caucasian male referred to the clinic after experiencing a feeling of a heart attack. He stated that he experienced dyspnea, chest tightness, and a feeling of impending doom. The client still experiences episodic shortness of breath and chest tightness. Medical history reveals that he is mild hypertensive and is currently on a sodium-restrictive diet to manage his disease. He also had his tonsils successfully removed when he was eight. The patient admits to taking alcohol occasionally to lessen his worries at work. He currently takes three to four beers every night. The patient is single. However, he reports that he maintains some responsibility as he is attempting to care for his parents. He works at a steel fabrication company and reports that the management at his workplace is harsh and that he fears losing his job. His medication history is negative for psychotropic medication use.
A mental status exam revealed that the client is alert, and oriented to place, event, and time of day. He was also appropriately dressed for the occasion and demonstrated goal-directed, coherency, and clarity in speech. His effect was somehow blunted. He denied suicidal ideation or tendencies, hallucinations, or paranoid thoughts. His judgment was intact. A physical examination of the patient revealed that he is overweight by about 15 lbs. Other physical exam parameters were within normal limits. ER and the EKG readings were normal, ruling out myocardial infarction. The client’s HAM-A score was 26.
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The patient presented with shortness of breath, chest tightness, and the feeling of impending doom. These manifestations are suggestive of an anxiety attack. Laboratory and diagnostic findings in this client’s case ruled out myocardial infarction, which is a differential in this case. The client, in the case, had mild hypertension. Elevated blood pressure may trigger anxiety (Abdisa et al., 2022). Hypertensive symptoms may also cause panic or anxiety. This may be the case for this client. The client’s work environment is also tense. As evident in the case, the client noted that the management at his workplace was harsh and that he feared losing his job. Notably, work-related stress is a risk factor for anxiety attacks. The client’s work environment may have contributed to his current presentations (Pfaffinger et al., 2020). The general anxiety disorder diagnosis was confirmed by a HAM-A score of 26, indicating moderate to severe anxiety.
Decision Point One: Begin Paxil 10 mg PO daily
Upon confirmation of the diagnosis, the first decision point is to begin Paxil at 10 mg every 24 hours. Paxil, paroxetine, is a selective serotonin reuptake inhibitor (SSRI). Along with other medications in this pharmacological class, this medication maintains use as the first line in the management of generalized anxiety disorder. Its tolerability and effectiveness in lessening anxiety symptoms informed its selection for this condition. Additionally, its once-daily dosing promotes compliance and is acceptable to many clients (Li et al., 2020). It is, thus, a medication of choice for this patient.
Imipramine, a tricyclic antidepressant (TCA), is also effective in the management of generalized anxiety. Its antihistaminic effects may, however, lead to dizziness and sedation, which may be unfavourable to the client due to his nature of work (Melaragno, 2021). Buspirone is another FDA-approved medication for the management of anxiety. However, it is reserved as a second-line agent for this indication. Dizziness is also common with Buspirones’s use (Melaragno, 2021). This makes its selection unfavourable to the client.
The selection of Paxil was aimed at lessening the severity of anxiety symptoms. This medication maintains effectiveness in addressing anxiety symptoms. Its tolerability and effectiveness warrant its use in this scenario (Li et al., 2020). The expected outcome was the resolution of anxiety symptoms due to the effectiveness of Paxil in managing anxiety (Li et al., 2020). When treating this client, his work history has to be taken into consideration. Working in a steel fabrication plan where the risk for injury is high, medications considered should be those that maintain his mental functioning per the ethical consideration of non-maleficence that requires caregivers to do no harm to their clients. Buspirone and Imipramine use may predispose the client to injuries due to their potential to cause sedation and dizziness among their users. Thus, it may be unethical to give the client these medications.