BACKGROUND INFORMATIONThe client is a 26-year-old woman of Korean descent who presents to her first appointment following a 21-day hospitalization for the onset of acute mania. She was diagnosed with bipolar I disorder.Upon arrival in your office, she is quite “busy,” playing with things on your desk and shifting from side to side in her chair. She informs you that “they said I was bipolar, I don’t believe that, do you? I just like to talk, and dance, and sing. Did I tell you that I liked to cook?”She weighs 110 lbs. and is 5’ 5” SUBJECTIVEPatient reports a “fantastic” mood. Reports that she sleeps about 5 hours/night to which she adds “I hate sleep, it’s no fun.”You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits. You find that the patient had genetic testing in the hospital (specifically GeneSight testing) as none of the medications that they were treating her with seemed to work.Genetic testing reveals that she is positive for the CYP2D6*10 allele.The patient confesses that she stopped taking her lithium (which was prescribed in the hospital) since she was discharged two weeks ago. MENTAL STATUS EXAMThe patient is alert, oriented to person, place, time, and event. She is dressed quite oddly- wearing what appears to be an evening gown to her appointment. Speech is rapid, pressured, tangential. The self-reported mood is euthymic. Affect broad. The patient denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, but insight is clearly impaired. She is currently denying suicidal or homicidal ideation.The Young Mania Rating Scale (YMRS) score is 22 RESOURCES§ Chen, R., Wang, H., Shi, J., Shen, K., & Hu, P. (2015). Cytochrome P450 2D6 genotype affects the pharmacokinetics of controlled-release paroxetine in healthy Chinese subjects: comparison of traditional phenotype and activity score systems. European Journal of Clinical Pharmacology, 71(7), 835-841. doi:10.1007/s00228-015-1855-6 RESULTS OF DECISION POINT ONEBegin Seroquel XR 100mg orally at night time· Client returns to the clinic in four weeks· Client is reporting that she sleeps a bit more at bedtime· Client states that she has gained about 2 or 3 pounds, which she does not like· Client also reports that she has been constipated since starting this medication· Client is also complaining of dry mouth which she does not like.· Client’s score on the Young Mania Rating Scale has decreased from a 22 to an 18· Client is reporting a really good mood but is asking for a different medication because of the weight gainRESULTS OF DECISION POINT TWO Discontinue Seroquel start Geodon 40mg orally twice a day with 500 calories meal The client returns to the clinic in four weeks The client demonstrates a 50% decrease in score on the Young Mania Rating Scale (from 22 to 11) The client denies any additional weight gain and denies any additional side effectsContinue with the same dose and reassess in 4 weeksGuidance to Studentyou should provide counseling to the client about this side effect and encourage increased fluids and fiber in the diet to combat constipation. Hard candies or gum can be used to prevent dry mouth. This is another issue as the drug can cause dental problems as a result of dry mouth.Changing to Geodon clearly helped with symptoms and arrested weight gain in this client. You could wait 4 weeks and see if any changes in the Young Mania Rating Scale are noted, or increase to 60 mg orally BID in an attempt to hasten symptom improvement. The increasing dose may be associated with side effects.Augmentation with Lithium may be appropriate if the goal of therapy is to discontinue antipsychotic therapy and treat it with Lithium monotherapy. Lithium was problematic for this client but changing formulation to the extended-release may overcome the difficulties she was experiencing with side effects. You would need to educate the client regarding the side effects of medication and the need to maintain compliance. Examine Case Study: An Asian American Woman. Diagnosis-Bipolar Disorder. 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 (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.
