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Unit 7 Assignment - Case Study Discussion

Denise Durham

Herzing University

NU670 Advanced Psychopharmacology

Vardah Seraphin, DNP, PMHNP-BC, FNP-C, APRN

August 27, 2021

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Unit 7 Assignment - Case Study Discussion

A 56 yr. old woman signs up with you as her new primary care physician. Her previous

diagnosis included hyperlipidemia, hyperglycemia, moderate obesity, and hypertension. Her

medications include; Paroxetine 20 mg for 10 years; Quetiapine 150 mg daily for 2 yrs.;

Irbesartan 300 mg daily for 1 yr.; and Atorvastatin 10 mg daily for 1 yr.

Labs: FBS = 126, HgbA1C = 6.2, total cholesterol = 200, LDL = 105, HDL = 35, Tg

=286. His present height equal 5’9” and weight = 210 lbs. His BP is 140/84.

She tells you that about 10 yrs. ago she became depressed and was started on Paroxetine

and gained 30lbs after 1 yr. Her mood at that time was much improved and remained that way

for about 2 yrs. At that time, Quetiapine was added, and she achieved remission of her

depression. Six months after this she gained another 20lbs, developed mild hypertension,

hyperglycemia, and hyperlipidemia. All other labs including thyroid testing were normal. She

tells you that she has a craving for carbohydrates and does little exercise since developing

depression about 15 yrs. ago.

What advice or modifications to her treatment regimen would you recommend for

your new patient?

This 56-year-old female patient presents with pre-diabetes as evidenced by a FBS of 126

and a HgbA1C of 6.2. A HgbA1C of greater than or equal to 6.5% is diabetes mellitus

(McCaffrey DNP ARNP FNP-BC GNP-BC FAANP, Ruth et al., 2021). She is also at risk for

cardiovascular disease due to her borderline total cholesterol of 200, slightly elevated LDL of

105, a low HDL of 35, and a high triglyceride level of 286. According to the Center for Disease

Control and Prevention (2021), total cholesterol should be less than 200, LDL less than 100,

HDL greater than 60, and triglycerides less than 150. The patient is on Irbesartan 300 mg daily

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for one year and Atorvastatin 10 mg daily for one year, as well. BP is 140/84 which is borderline,

blood pressure should be less than 140/90.

The patient has been on Paxil 20 mg daily for ten years and Seroquel 150 mg daily for

two years. During this time the patient gained a total of fifty pounds but achieved remission of

her depression. The patient’s BMI is 31 which is considered obese, an appropriate weight range

for her would be 125.3 to 168.6 pounds (National, Heart, Lung and Blood Institute, 2021). With

the additional weight gain, six months after the patient developed mild hypertension,

hyperlipidemia, and hyperglycemia. Thyroid levels are normal but, the patient states she is

experiencing cravings for carbohydrates and has done little exercise since developing depression

about fifteen years ago.

My treatment plan would be to discontinue both the Paroxetine and Quetiapine and

change the patient to Wellbutrin XL. I would discontinue the Paroxetine first using a

conservative taper which is 5 half-lives and Paroxetine has a 1-day half-life so it is

approximately five days, at this point, I would start the Wellbutrin XL at 150 mg daily and then

start a conservative taper of Quetiapine which has a half-life of 6-7 hours so five half-lives would

take about 2 days. Wellbutrin XL is associated with weight loss(Stahl, 2020). Wellbutrin XL also

has a side effect of hypertension and for that reason, I would add 25 mg of hydrochlorothiazide

to the 300 mg of Irbesartan.

My second treatment plan would be a lifestyle change to include exercise and diet

modification. According to the Mayo Clinic (2021), 150 minutes of moderate physical activity a

week, and reducing caloric intake will help with weight loss.

If you suggested additional medication, look up your state’s prescribing laws. Are

PMHNP’s able to prescribe the medication you recommended?

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Yes, as a practicing PMHNP for the state of Georgia I would be able to prescribe these

medications as long as I have a Nurse Protocol Agreement with a delegating physician submitted

to the Georgia Medical Board (Georgia Medical Board, 2010).

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References

Center for Disease Control and Prevention. (2021, April 15). Getting your cholesterol checked.

Centers for Disease Control and Prevention.

https://www.cdc.gov/cholesterol/cholesterol_screening.htm

Georgia Medical Board. (2010). Microsoft word - faq's - np _updated_.doc [PDF].

https://medicalboard.georgia.gov/sites/medicalboard.georgia.gov/files/imported/GCMB/F

iles/FAQs NP May 2010.pdf

McCaffrey DNP ARNP FNP-BC GNP-BC FAANP, Ruth, Reinoso PhD FNP-BC ENP-BC,

Humberto, & Reinoso PhD FNP-BC ENP-BC, Humberto. (2021). Np notes: Nurse

practitioner's clinical pocket guide (Fourth ed.). F.A. Davis Company.

National, Heart, Lung and Blood Institute. (2021). Calculate your bmi - standard bmi calculator.

National Heart, Lung, and Blood Institute.

https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

Stahl, S. M. (2020). Prescriber's guide: Stahl's essential psychopharmacology (7th ed.).

Cambridge University Press.

The Mayo Clinic. (2021). Weight loss. Mayo Clinic. Retrieved August 27, 2021, from

https://www.mayoclinic.org/healthy-lifestyle/weight-loss/basics/diet-and-exercise/hlv-

20049483

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