{"id":26856,"date":"2021-01-20T08:52:01","date_gmt":"2021-01-20T08:52:01","guid":{"rendered":"http:\/\/onlineclassesguru.com\/?p=26856"},"modified":"2021-01-20T08:52:01","modified_gmt":"2021-01-20T08:52:01","slug":"post-a-response-to-the-following-provide-the-case-number-in-the-subject-line-of-the-discussion-thread-list-three-questions-you-might-ask-the-patient-if-he-or-she-were-in-your-office-provide-a-ratio","status":"publish","type":"post","link":"https:\/\/onlineclassesguru.com\/index.php\/2021\/01\/20\/post-a-response-to-the-following-provide-the-case-number-in-the-subject-line-of-the-discussion-thread-list-three-questions-you-might-ask-the-patient-if-he-or-she-were-in-your-office-provide-a-ratio\/","title":{"rendered":"Post a response to the following: Provide the case number in the subject line of the Discussion thread. List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions. Id"},"content":{"rendered":"<style type=\"text\/css\"><\/style><p><b>Case 2:\u00a0<\/b>Volume 1, Case #7: The case of physician do not heal thyself<\/p>\n<p>PATIENT FILE 69 The Case: The case of physician do not heal thyself The Question: Does the patient have a complex mood disorder, a personality disorder or both? The Dilemma: How do you treat a complex and long-term unstable disorder of mood in a diffi cult patient? Pretest Self Assessment Question (answer at the end of the case) Frequent mood swings are more a sign or symptom of a mood disorder than they are of a personality disorder A. True B. False Patient Intake \u2022 60-year-old man \u2022 Chief complaint is \u201cbeing unstable\u201d \u2022 Patient estimates that he has spent about two thirds of the time over the past year being in a mixed dysphoric state and about one third as depressed, but waxing and waning every few days, or even every few hours Psychiatric History: Childhood and Adolescence \u2022 As a young child, had symptoms of generalized anxiety and separation anxiety \u2022 Also, as a child, remembers \u201cemotional trauma\u201d from mother, herself with recurrent episodes of either unipolar or bipolar depression who was often physically unavailable because of hospitalizations, or emotionally distant when depressed at home \u2022 Has had a lifetime of multiple turbulent interpersonal relationships since childhood, with family members, with friends and especially with women \u2022 As an older child and adolescent, continued to have not only subsyndromal generalized anxiety but developed at least subsyndromal levels of OCD with ruminations, checking and rigidity \u2022 He was told these were good traits and would make him a good student, which he was, with good grades through high school and college, gaining admission to medical school Psychiatric History: Adulthood \u2022 Diagnosed as major depression for the fi rst time at age 23, early in medical school \u2013 Was his worst depression so far, as other depressions previously Downloaded from http:\/\/stahlonline.cambridge.org by IP 192.168.60.239 on Wed Jun 14 08:38:53 BST 2017 Stahl\u2019s Essential Psychopharmacology Online \u00a9 2017 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE 70 characterized as unhappiness and transient depressed moods of a few days duration and with more anxiety than depression, improving without treatment \u2013 Actively suicidal and overdosed on his medications at this time but recovered \u2013 In retrospect, patient believes that he has long experienced rejection sensititivity with up to 2 depressive episodes per year since age 16 up to the present \u2022 No clear history of any full syndromal manic or hypomanic episodes \u2022 Since age 23, however, has had many episodes lasting a week or more of irritability, infl ated self esteem, increased goal-directed work activity, decreased need for sleep, overtalkativeness, racing thoughts, psychomotor agitation and risky behavior; could also experience euphoria or expansiveness to a signifi cant degree but only for 2 or 3 days at most and usually shorter \u2022 He interpreted these as good traits, indicative of creative persons, and were the reason he was productive as well as creative \u2022 In getting his history, it is not clear whether he has had an irritable dysphoric temperament since childhood, a superimposed episodic subsyndromal dysphoric mixed hypomania, or both \u2022 First marriage ages 32\u201333 \u2013 Depressive episode and overdosed again when fi rst marriage broke up \u2022 Second marriage between 35 and 36 \u2013 Another depressive episode after breakup of this marriage \u2022 Third marriage ages 46 to 58 \u2013 Another depressive episode after breakup of this marriage Medication History \u2022 Starting with his fi rst diagnosed episode of depression in medical school, treated off and on with TCAs and benzodiazepines, starting and stopping them over many years in relationship to his symptoms \u2022 First received lithium at age 43, 17 years ago \u2022 Unclear whether this was an augmentation strategy for resistant depression or for bipolar spectrum symptoms \u2022 Was not that helpful according to the patient \u2022 States he has had many, many medication trials since then \u2022 Valproate (Depakote) not tolerated \u2022 Clonazapam (Klonopin) helped sleep \u2022 Oxcarbazapine (Trileptal) caused dysphoria and agitation \u2022 Verapamil caused\/worsened depression \u2022 Risperidone (Risperdal) caused depression \u2022 Fluoxetine (Prozac) caused rapid fl eeting relief of depression, but also insomnia and headache Downloaded from http:\/\/stahlonline.cambridge.org by IP 192.168.60.239 on Wed Jun 14 08:38:53 BST 2017 Stahl\u2019s Essential Psychopharmacology Online \u00a9 2017 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE 71 \u2022 Other SSRIs caused activation and were not tolerated and discontinued after a few doses \u2022 Presents now only taking methylphenidate (Ritalin), which he prescribes for himself as he does not think his physicians know as much about his case, or what he needs, as he does and they will not prescribe it for him Social and Personal History \u2022 Married and divorced 3 times, currently single \u2022 No children \u2022 Non smoker \u2022 No drug abuse, rarely drinks \u2022 Physician and successful businessman Medical History \u2022 Crohn\u2019s disease Family History \u2022 Father: sleep disorder \u2022 Mother: either bipolar or unipolar depression, unsure, but successfully treated with ECT \u2022 Maternal uncle: depression \u2022 Maternal aunt: depression \u2022 Maternal grandmother: hospitalized for \u201cmanic depressive disorder\u201d Current Medications \u2022 Azothiaprine and Remicaid for Crohn\u2019s \u2022 Methylphenidate Based on just what you have been told so far about this patient\u2019s history what do you think is his diagnosis? \u2022 Recurrent major depression with an anxious\/dysphoric temperament \u2022 Bipolar II depression \u2022 Bipolar II mixed episode \u2022 Bipolar NOS \u2022 Bipolar NOS superimposed upon a personality disorder (narcissistic, borderline, other) \u2022 Primarily a cluster B personality disorder (antisocial\/histrionic\/ narcissistic\/borderline) Downloaded from http:\/\/stahlonline.cambridge.org by IP 192.168.60.239 on Wed Jun 14 08:38:53 BST 2017 Stahl\u2019s Essential Psychopharmacology Online \u00a9 2017 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE 72 Attending Physician\u2019s Mental Notes: Initial Psychiatric Evaluation \u2022 Here is a case that could be a complex combination of a mood disorder plus a personality disorder in someone who has never experienced mania and probably has never reached the threshold of experiencing unequivocal hypomania as defi ned by DSM IV or ICD10 \u2022 It is very diffi cult to separate the mood disorder from the personality disorder in a one hour initial evaluation session, plus looking at the medical records \u2022 A complete diagnosis will have to await spending more time with the patient, and if possible, having access to the input of other observers as well \u2022 However, seems likely that there is more to this case than a mood disorder, and probably cluster B personality traits if not personality disorder is comorbid How would you treat him? \u2022 Continue his methylphenidate \u2022 Discontinue his methylphenidate \u2022 Start an antidepressant \u2022 Restart lithium \u2022 Start an anticonvulsant mood stabilizer \u2022 Start an atypical antipsychotic \u2022 Make sure he agrees to weekly insight oriented psychotherapy \u2022 Consider psychoanalysis Attending Physician\u2019s Mental Notes: Initial Psychiatric Evaluation, Continued \u2022 Since the patient lives in another city, psychotherapy will have to be an option via another mental health professional, although some supervision of that plus advice on medications can be possible as a consultant \u2022 The patient is open to pursuing psychotherapy as long as he respects the therapist \u2022 Before recommending psychopharmacologic treatment, it would be good to review what we know from the available history about his response to medications already taken \u2022 As shown from the history of this case, it can be impossible to determine with great accuracy the effects of the medications by taking a history. One should be skeptical of the information as it can be unreliably reported in records and by a patient because it is complex and the medication effects can be subtle Downloaded from http:\/\/stahlonline.cambridge.org by IP 192.168.60.239 on Wed Jun 14 08:38:53 BST 2017 Stahl\u2019s Essential Psychopharmacology Online \u00a9 2017 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE 73 \u2013 How many medications were taken long enough to have had a chance to work? \u2013 Did some medications provoke mood instability while others stabilized mood? \u2013 If the person has a mood disorder with an underlying personality disorder, will medications treat only the mood disorder and expose the symptoms of the personality disorder, or \u2013 Will treating the mood disorder with medications allow the patient to recompensate and thus have improvement not only in mood but in personality disorder symptoms? \u2013 These questions are better answered if you live the ups and down along with the patient and experience the signs and symptoms of such a patient in real time \u2013 However, the real question is what can you do to help such a patient and what are the realistic goals of treatment \u2013 Finally, is treatment defi ned as medications, insight oriented psychotherapy, or both? \u2022 About the only thing solid here is that antidepressants seem to be provocative at times in terms of causing activation and thus should be given cautiously and only concomitantly with mood stabilizing medication \u2022 Has taken numerous mood stabilizing medications that he reported cause depression, especially those that are used to treat mania \u2022 He has a demanding job and is not willing to put up with much sedation and will not accept weight gain \u2022 It is possible that he is a bipolar spectrum patient with more depression than mania and with more pure depressive states alternating with mixed states of dysphoria\/irritability superimposed upon depression, but not full syndrome mixed bipolar disorder \u2022 Thus he has four needs\u201d \u2013 Treat from \u201cbelow\u201d (i.e., antidepressant) \u2013 Stabilize from \u201cbelow: (i.e. prevent cycling into depression) \u2013 Treat from \u201cabove\u201d (in his case, not to treat euphoric mania, but to treat irritability) \u2013 Stabilize from \u201cabove\u201d (i.e. prevent cycling into mixed states of dysphoric\/irritable depression) \u2022 Highly unlikely that this will be possible with a single agent \u2022 For now, decided to avoid an antidepressant and to stop the methylphenidate which may help depression but at the expense of destabilizing him and causing cycling into irritable mixed states \u2022 For now, a low side effect mood stabilizing agent with antidepressant and maintenance potential (i.e., treating from below and stabilizing from below) such as lamotrigine seems to be a good bet Downloaded from http:\/\/stahlonline.cambridge.org by IP 192.168.60.239 on Wed Jun 14 08:38:53 BST 2017 Stahl\u2019s Essential Psychopharmacology Online \u00a9 2017 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE 74 \u2022 After this is given, might consider adding lithium which he has tolerated in the past although unclear what therapeutic actions it had for him; however, might treat and stabilize him from above in synergy with lamotrigine for a total therapeutic picture Case Outcome: First Interim Followup, Week 12 \u2022 Patient fl ies back for a followup appointment 3 months later \u2022 Has stopped methylphenidate and his psychiatrist in his home city started lamotrigine by slow upward titration, but a bit faster and to a higher dose than recommended and now taking 400 mg\/day \u2022 Mood stabilized but at a level of low grade consistent depression with decreased libido and sexual dysfunction \u2022 Told to reduce lamotrigine to 200 mg and wait another month or two because it can take a while yet for lamotrigine\u2019s antidepressant effect to kick in and its mood stabilizing effects may have already started Case Outcome: Second Interim Followup, Week 16 \u2022 Phone consultation \u2022 Learned that the patient decided that lamotrigine was making him depressed and ruining his sex life, so discontinued it and completely relapsed in terms of depression \u2022 Patient agrees to restart lithium after blood and urine tests from his physician Case Outcome: Third, Fourth, and Fifth Interim Followup Visits, Weeks 20, 24 and 28 \u2022 Phone consultations \u2022 Patient has normal labs and starts lithium at week 20 only has a blood level of 0.4, so told to increase dose \u2022 At week 24 calls and states that higher doses give him unacceptable diarrhea and exacerbates his Crohn\u2019s disease symptoms, so he is back down to the low dose of lithium \u2022 Also, restarted methylphenidate as needed for dysphoric mood and low energy \u2022 Told to increase his lithium again, more slowly and not to 1800 mg\/ day which caused diarrhea but only to 1500 mg a day or 1500 mg alternating with 1800 mg\/day on alternate days and to stop his methylphenidate \u2022 Also told to restart lamotrigine titrating up to only half his previous dose, namely 200 mg\/day with the strategy that both drugs together would allow him to take each in lower tolerable doses for him, yet working together to add their therapeutic effects Downloaded from http:\/\/stahlonline.cambridge.org by IP 192.168.60.239 on Wed Jun 14 08:38:53 BST 2017 Stahl\u2019s Essential Psychopharmacology Online \u00a9 2017 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE 75 Case Outcome: Sixth and Seventh Interim Followup Visits, Weeks 32 and 36 \u2022 Brief phone consults with the patient and his psychiatrist on the phone together \u2022 Getting regular psychotherapy \u201cwhatever\u201d \u2022 Monitored by his local psychiatrist monthly face to face appointments \u2022 Lithium level 0.7, occasional tremor and diarrhea but mostly tolerable \u2022 Mood is stable and overall \u201cfeels much better\u201d Case Outcome: Eighth Interim Followup, Week 40 \u2022 Emergency phone call \u2022 Can\u2019t get a hold of his psychiatrist where he lives \u2022 Patient calls from a football stadium where his alma mater is playing in a big football game \u2022 \u201cI\u2019m in trouble\u201d \u2022 Patient states he has been much troubled recently about always feeling somewhat dysphoric, not really worse recently, but just tired of never being \u201cwell\u201d \u2022 Denies psychosocial stressors but feels desperate and suicidal \u2022 Now at the football game, his thoughts are entirely about suicide, making his will, shooting others at the game, and killing himself \u2022 Fortunately, he states he neither has a gun with him nor does he own one \u2022 Has weird reaction to the football game, because when his team scores, he is not euphoric but bursts into tears \u2022 \u201chelp me\u201d What would you do now? \u2022 Tell him to call his local psychiatrist \u2022 Tell him to go to the emergency room \u2022 Tell him to call the suicide hot line \u2022 Tell him to settle down and that you will either call in a prescription for an antipsychotic or coordinate it with his local psychiatrist \u2022 Tell the patient to fi nd another consultant Downloaded from http:\/\/stahlonline.cambridge.org by IP 192.168.60.239 on Wed Jun 14 08:38:53 BST 2017 Stahl\u2019s Essential Psychopharmacology Online \u00a9 2017 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE 76 Case Outcome: Eighth Interim Followup, Week 40, Continued \u2022 Told the patient to settle down and you would call his psychiatrist to meet him at his local emergency room which he agrees to do after the game ends \u2022 Also patient states he feels much better now that he has spoken on the phone, and also now that his team is now winning \u2022 Local psychiatrist sees him in the emergency room and starts him on aripiprazole 2.5 mg increasing if tolerated and not effective to 5.0 mg 1 to 3 days later, increasing to 7.5 mg if tolerated and not effective 1 to 3 days later Case Outcome: Ninth Interim Followup, Week 41 \u2022 One week later, phone consult with his psychiatrist on the line \u2022 Patient states he contacted his local psychiatrist the same day as his phone call from the football stadium, and saw him a week later (which was yesterday) \u2022 Got the prescription for aripiprazole and the next day following the phone call from the football stadium, left on a business trip from California to New York \u2022 In New York, the aripiprazole was not effective at 2.5 mg, so the next day he became desperate and took 20 mg (not an overdose attempt, just to hurry up the therapeutic response) \u2022 Also increased his lamotrigine on his own to 400 mg\/day \u2022 Lowered his lithium dose \u2022 Flew back to California \u2022 Had gait disturbance, tremor, word-fi nding problems, memory loss, yet still verbally provocative, desperate with recurring suicidal and homicidal ideation \u2022 \u201cI want to hang myself\u201d What would you do now? \u2022 Start another antipsychotic \u2022 Reinstate the original doses of lamotrigine and lithium \u2022 Tell the patient and his local psychiatrist to fi nd another consultant Case Outcome: Ninth Interim Followup, Week 41, Continued \u2022 Actually, this time, felt as though the patient was manipulating and scolded him with his psychiatrist on the line \u2022 Told him that his psychiatrist is the treating physician, not the consultant, and the consultant\u2019s advice is to see his psychiatrist and to have future contacts with the consultant either by phone with his psychiatrist on the line, or face to face with his psychiatrist on the line Downloaded from http:\/\/stahlonline.cambridge.org by IP 192.168.60.239 on Wed Jun 14 08:38:53 BST 2017 Stahl\u2019s Essential Psychopharmacology Online \u00a9 2017 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE 77 \u2022 Told to decrease lamotrigine, increase lithium back to previous levels and to discontinuie aripiprazole \u2022 Also advised starting ziprasidone 40 mg at night with food Case Outcome: Tenth Interim Followup, Week 42 \u2022 Phone call with local treating psychiatrist and the patient one week later \u2022 Patient was compliant with instructions \u2022 Now states the ziprasidone \u201cturned a switch\u201d \u2022 By this he means that suicidal ideation abated immediately, depression no longer dysphoric but only low grade at worst \u2022 Some fatigue\/inertia \u2022 Some tongue chewing suggesting a mild ziprasidone induced EPS \u2022 Dramatically better and very pleased \u2022 Suggest to them that the consultant will now resign from the case \u2022 Did he live happily every after? Case Outcome: Eleventh Interim Followup, Week 54 \u2022 About 3 months later, that is, 1 year after the initial psychiatric evaluation, got phone call from a new psychiatrist in the patient\u2019s home city where the patient had transferred his care \u2022 States that the patient decided to add fl uoxetine 10 mg, stopped lamotrigine, tried 160 mg of ziprasidone, now back to 40 mg \u2022 The story goes on. . . . Case Debrief \u2022 This intelligent and manipulative patient with a genuine mood disorder and a personality disorder is decidedly unstable, but able to function as a physician even though not able to maintain long-term interpersonal relationships \u2022 Is not very compliant, often making therapeutic decisions on his own about how to treat his own case, especially when things are not going well \u2022 It is diffi cult to determine whether his periods of mood stability are related to drug treatment or to the lack of psychosocial stressors, but there is the sense that medications are somewhat helpful for the worst of his mood swings even though the medications are not helpful for his responses to psychosocial stressors Downloaded from http:\/\/stahlonline.cambridge.org by IP 192.168.60.239 on Wed Jun 14 08:38:53 BST 2017 Stahl\u2019s Essential Psychopharmacology Online \u00a9 2017 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE 78 Take-Home Points \u2022 Diffi cult patients are diffi cult \u2022 To paraphrase Tolstoy in Anna Karenina \u2013 \u201cHappy families are all alike; every unhappy family is unhappy in its own way\u201d \u2013 One could say in cases like this one, \u201cStable patients are all alike; every unstable patient is unstable in his own way\u201d \u2022 Temperament and personality are factors in bipolar disorder and might even be part of bipolar disorder and are certainly part of the barriers to treatment effectiveness and to treatment compliance\/adherence \u2022 A realistic goal in a case like this may be less of a roller coaster, but not full stabilization or true remission, yet well enough to stay employed, have relationships and not be desperate, suicidal or homicidal \u2022 Patients tend to hate depressed states more than mixed states whereas those around patients tend to hate the patient\u2019s mixed irritable states more than their depressed states Performance in Practice: Confessions of a Psychopharmacologist \u2022 What could have been done better here? \u2013 Should the consultant have stayed engaged after the intial consultation? \u2013 The involvement of two psychiatrists allowed the patient the opportunity for splitting and chaos \u2013 Should psychotherapy have played a more prominent role here? \u2022 Possible action item for improvement in practice \u2013 Make a more concerted effort to defi ne the role of a consultant versus a primary psychiatrist, who is the quarterback of the team, allowing the consultant to play a secondary role, and perhaps in cases like this, try and ensure no direct contact with the consultant without the primary psychiatrist also being present \u2013 Set realistic goals for a patient like this and realize long term stability may not be attainable Tips and Pearls \u2022 Lamotrigine, lithium and an atypical antipsychotic can be a useful triple combination for unstable cases of mood and personality disorder and combinations and doses can be found that are relatively tolerable \u2022 Stimulants have no role in a case like this \u2022 Antidepressants can be destabilizing in a case like this \u2022 Physicians can be especially diffi cult to treat when they are patients as they tend to interfere with their own treatments Downloaded from http:\/\/stahlonline.cambridge.org by IP 192.168.60.239 on Wed Jun 14 08:38:53 BST 2017 Stahl\u2019s Essential Psychopharmacology Online \u00a9 2017 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE 79 Table 2: Personality disorders vs mood disorders \u2022 Cluster A disorders (paranoid, schizoid personality disorders or schizotypal personality disorder) \u2013 Tend to overlap with psychotic mood disorders \u2022 Cluster B disorders (antisocial, borderline, histrionic and narcissistic personality disorders) \u2013 Can be easily confused for a bipolar spectrum disorder \u2013 Especially if no overt manic episode or any unequivocal hypomanic episode \u2013 Nevertheless, symptoms can empirically improve when treated with agents for bipolar disorder \u2013 A very confusing and chaotic condition can be the combination of a bipolar disorder with a cluster B personality disorder \u2022 Cluster C disorders (avoidant, dependent and obsessive compulsive personality disorders) \u2013 Can be confused with anxiety disorders \u2013 Often predate the emergence of a mood disorder and can reappear when mood disorder symptoms under control Table 1: General symptoms of a personality disorder overlap with general symptoms of a mood disorder, particularly a bipolar spectrum mood disorder \u2022 Frequent mood swings \u2022 Anger outbusts \u2022 Stormy professional and personal relationships \u2022 Social isolation \u2022 Suspicion and mistrust of others \u2022 Diffi culty making friends \u2022 Need for instant gratifi cation \u2022 Poor impulse control \u2022 Frequent drug or alcohol abuse Two-Minute Tute: A brief lesson and psychopharmacology tutorial (tute) with relevant background material for this case \u2013 Distinguishing personality disorders from mood disorders Downloaded from http:\/\/stahlonline.cambridge.org by IP 192.168.60.239 on Wed Jun 14 08:38:53 BST 2017 Stahl\u2019s Essential Psychopharmacology Online \u00a9 2017 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE 80 Posttest Self Assessment Question: Answer Frequent mood swings are more a sign or symptom of a mood disorder than they are of a personality disorder A. True B. False Answer: False Mood swings are prominent signs of both mood disorders and personality disorders; not all mood swings are mood disorders References 1. Stahl SM, Mood Disorders, in Stahl\u2019s Essential Psychopharmacology, 3rd edition, Cambridge University Press, New York, 2008, pp 453\u2013510 2. Stahl SM, Antidepressants, in Stahl\u2019s Essential Psychopharmacology, 3rd edition, Cambridge University Press, New York, 2008, pp 511\u2013666 3. Stahl SM, Mood Stabilizers, in Stahl\u2019s Essential Psychopharmacology, 3rd edition, Cambridge University Press, New York, 2008, pp 667\u2013720 4. Stahl SM, Lamotrigine in Stahl\u2019s Essential Psychopharmacology The Prescriber\u2019s Guide, 3rd edition, Cambridge University Press, New York, 2009, pp 259\u201366 5. Stahl SM, Lithium, in Stahl\u2019s Essential Psychopharmacology The Prescriber\u2019s Guide, 3rd edition, Cambridge University Press, New York, 2009, pp 277\u201382 6. Stahl SM, Ziprasidone, in Stahl\u2019s Essential Psychopharmacology The Prescriber\u2019s Guide, 3rd edition, Cambridge University Press, New York, 2009, pp 589\u201394 7. Stahl SM, Aripiprazole, in Stahl\u2019s Essential Psychopharmacology The Prescriber\u2019s Guide, 3rd edition, Cambridge University Press, New York, 2009, pp 45\u201350 8. Schwartz TL and Stahl,SM, Ziprasidone in the treatment of bipolar disorder, in Akiskal H and Tohen M, Bipolar Psychopharmacotherapy: Caring for the Patient, 2nd edition, Wiley Press Downloaded from http:\/\/stahlonline.cambridge.org by IP 192.168.60.239 on Wed Jun 14 08:38:53 BST 2017 Stahl\u2019s Essential Psychopharmacology Online \u00a9 2017 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized<\/p>\n<p><b>By Day 3<\/b><\/p>\n<p><b>Post<\/b>\u00a0a response to the following:<\/p>\n<ul>\n<li>Provide the case number in the subject line of the Discussion thread.<\/li>\n<li>List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.<\/li>\n<li>Identify people in the patient\u2019s life you would need to speak to or get feedback from to further assess the patient\u2019s situation. Include specific questions you might ask these people and why.<\/li>\n<li>Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.<\/li>\n<li>List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.<\/li>\n<li>List two pharmacologic agents and their dosing that would be appropriate for the patient\u2019s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.<\/li>\n<li>For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client\u2019s ethnicity. Discuss why the contraindication\/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?<\/li>\n<li>If your assigned case includes \u201ccheck points\u201d (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.<\/li>\n<li>Explain \u201clessons learned\u201d from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations<\/li>\n<\/ul>\n<p><center><a href=\"http:\/\/onlineclassesguru.com\/orders\/ordernow\"><img decoding=\"async\" src=\"https:\/\/encrypted-tbn0.gstatic.com\/images?q=tbn:ANd9GcTyj99p60XCLyLk1htB7-1neRt8-2QdnenNlQ&usqp=CAU\"target=\"_http:\/\/onlineclassesguru.com\/orders\/ordernow\"\/><\/center><p>","protected":false},"excerpt":{"rendered":"<p>Case 2:\u00a0Volume 1, Case #7: The case of physician do not heal thyself PATIENT FILE 69 The Case: The case of physician do not heal thyself The Question: Does the patient have a complex mood disorder, a personality disorder or both? The Dilemma: How do you treat a complex and long-term unstable disorder of mood&#8230;<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-26856","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v17.0 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Post a response to the following: Provide the case number in the subject line of the Discussion thread. List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions. Id - onlineclassesguru<\/title>\n<meta name=\"description\" content=\"Post a response to the following: Provide the case number in the subject line of the Discussion thread. 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