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You are the NP seeing S.P., a 45 year old Caucasian female

You are the NP seeing S.P., a 45 year old Caucasian female, for the first time today.   She is an established patient of the practice for the past 6 years, previously under the care of another provider who has just retired. She presents to the clinic for a routine follow-up visit and refills for anxiety, depression, and chronic pain.

You review the chart prior to entering the exam room and note that S.P. has been seen monthly for the past 6 years for refills on Neurontin 800mg qid, Alprazolam 1mg, one po bid to tid prn.  and Citalopram (Celexa) 40mg po QD.  Her PCP prescribes Metoprolol ER 50mg po QD, and Atorvastatin 20mg po QD. She has been diagnosed with anxiety disorder with agoraphobia and major depressive disorder recurrent moderate.  The psychiatric provider recommended counseling, but she would not agree.

The chart contains several random UDS reports, which are all consistent with the medications prescribed and with no illicit medications being present.

She reports anxiety and “panic attacks” that occur an average of once/week but were as frequent as 5/week prior to being prescribed Alprazolam. She only leaves her home for medical appointments and rarely to visit a family member, and reports she does not even like to step out onto her porch because it makes her “so nervous.”  She has been unable to drive for years due to panic attacks.  Her depressive symptoms have been much improved on Celexa and she specifically denies suicidal or homicidal thoughts.

Alert & Oriented X 3; answers questions appropriately.  Memory intact for recent, recall, and remote.  Anxious and at times tearful during visit.

Please discuss how you would handle today’s office visit regarding continuing the previous provider’s plan of treatment for anxiety management and chronic pain management with the medications currently prescribed.  Your discussion should include, but is not limited to: 1. Ethical consideration. 2. Medication monitoring concerns and informed consent.  3. Patient safety considerations.  4. Recommendations for follow up and/or referral.