Assessing and Treating Patients with Anxiety Disorder

Anxiety disorders cause significant psychological and physical impacts on the patient health. This week’s decision scenario is of a 46-year-old white male referred by his primary care physician (PCP) because he felt he was having a heart attack. The patient was feeling shortness of breath, chest tightness, and a feeling of impending doom.

Assessing and Treating Patients with Anxiety Disorder

In the emergency room, a diagnosis of myocardial infarction was ruled out and special exam findings were within normal limits. The client admits that these have been similar episodes since then and he now refers to them as anxiety attacks.

He consumes about 3-4 beers per night. He also reports fears for his job and complains about a ‘harsh’ workplace environment. He reports that has never been on any psychotropic medication. The mental state examination done is positive for blunted affect and nervous mood.

The Hamilton Anxiety Rating Scale (HAM-A) was 26 showing moderate to severe anxiety. He is, therefore, diagnosed with a generalized anxiety disorder (GAD). The purpose of this paper is to describe my chokes for correct pharmacotherapy that will reduce this patient’s anxiety scale as evidenced by HAM-A score reduction in the first 12 weeks of medication therapy.

Decision Point #1

Begin Paxil 10 mg po daily

Reason for this Decision

Paxil, also known as paroxetine is a selective serotonin reuptake inhibitor (SSRI) with little effect on histaminergic and a-adrenergic receptors. According to Jin et al. (2022), SSRIs such as paroxetine are the forts line treatment for generalized anxiety disorder.

However, these medications are not devoid of adverse effects. I chose paroxetine because it is an SSRI and a well-tolerated medication that has been shown to improve daily functioning and anxiety symptoms. According to Strawn et al. (2018), paroxetine improved HAM-A scores in a double-blind, randomized control trial that involved paroxetine and other anxiolytic medications.

The patient in the given case scenario has a high HAM-A score, 26, which suggests severe anxiety. Reducing the HAM-A score will mean reducing anxiety symptoms which is the general goal of the management of this patient.

Reason for not Selecting Other Options

The other options, Zoloft 25mg orally daily and Wellbutrin 75 mg orally BID, are also viable treatment options for this patient’s treatment. Zoloft is an SSRI, while Wellbutrin is a norepinephrine dopamine reuptake inhibitor (NDRI).

Sertraline and paroxetine belong to the same pharmacological class with relatively similar tolerability and efficacy (Currow et al., 2019). I chose Paxil because it is generally cheaper, especially in the generic form. Wellbutrin is prescribed twice daily dosing, thus higher risk of noncompliance to medication prescription owing to the occupation of the patient, welding.

All medications were efficacious in relieving this patient’s anxiety. Sertraline and Wellbutrin were well tolerable but relatively expensive or had a dosing schedule that was more likely to cause medication noncompliance. Adorability of twice-daily dosing medication for 30 days is likely to be expensive and, thus, higher chances of nonadherence in the long term.

Expectations

With this decision, I hoped to reduce the patient’s anxiety symptoms, improve the patient quality of life and prevent the recurrence of symptoms. Therefore, I selected a medication that would have good pharmacological efficacy, be well tolerated, and whose prescription would be easily adhered to.

In the first four weeks, I expected to reduce the HAM-A score from 26 to below 20. Scores below 20 are mild to moderate. Therefore, I hope that the next time the patient returns to the office, he will present with mild anxiety and good compliance with his prescription. With this decision, I also hoped that the side effects of Paxil would not have a significant impact on the patient quality of life and that the beneficial outcomes of treatment would outweigh the risk of side effects.

Ethical Considerations

The decisions made are aimed at serving the patient’s best interest. Symptom reduction, improvement of quality of life, and prevention of recurrence of symptoms will uphold the ethical principle of beneficence. This decision overlooked the principle of do-no-harm by choosing a medication with a higher risk of side effects.

According to Strawn et al. (2018), the risk of adverse effects of Paxil is higher than that of Zoloft and Wellbutrin. Nevertheless, the risk of suicidal ideations is higher with these medications and would be an important ethical-legal consideration in clinical monitoring.

Decision Point #2

Paxil dose to 20 mg PO daily

Reason for Decision

Four weeks after decision #1, the client returned with symptom reduction and a HAM-A score of 18. This shows the achievement of my chief goal in decision one. However, the score also suggested a partial response. My decision point #2 was to increase the dose of Paxil to 20 once-daily dosings.

I selected this decision because the outcomes of the previous decision suggested that my pharmacotherapy was working but needed further improvements. Moreover, the patient did not report adverse effects of the medication. According to David et al. (2020), the side effects of Paxil are dose-dependent. Nevertheless, I would be worried about the patient’s suicidal risk at this point before the dose increment.

My Expectations

With this decision, I expected to reduce further the HAM-A score of the patient below 12. HAM-A score below 12 suggests mild anxiety. The patient has improved to moderate anxiety, but I would like to improve this objective score further to mild anxiety. Steady titration of Paxil doses has clinical benefits but also risk side effects. Therefore, with this decision, I hope to achieve symptomatic management but at the same time avoid adverse medication effects.

Reason for not Selecting the Other Options

The other two options suggested that I reduce the dose for seven days before returning to the normal dose. This step will increase symptoms and the reappearance of the feeling of chest tightness and shortness of breath. There would be no clinical reason to reduce the dose in the absence of side effects.

The option suggested that I change to Prozac, 10 mg orally. Prozac, called fluoxetine, is an SSRI with a similar mechanism of action as Paxil (Zhang et al., 2020). Paxil has proved to be well tolerated so far and partly efficacious at 10mg OD. Changing the regimen at this point will be of no clinical significance but risk newer side effects specific or more common with Prozac.

Ethical Considerations

At this point, the previous ethical goals had been achieved. No side effects and improvement in symptoms had been ensured. However, the need to prevent patient harm will be an ethical challenge as dose increment risks adverse effects while improving clinical symptoms further. Therefore, beneficence and non-maleficence principles clashed at this point.

Decision Point # 3

Maintain current dose

Reason for the Decision and Expectations

The client returned four weeks later with further reduction in his symptoms, and his HAM-A score was 10. This indicated mild anxiety and, thus, good control of anxiety symptoms. The decision. With this decision, I expect to control the patient’s clinical condition and quality of life. The client is responding well to the pharmacotherapy and changing the regimen could lead to the resurgence of the symptoms.

Therefore, I did not choose other options so that the good clinical progress of the patient is not put him at risk of deterioration. Dose maintenance at this point in therapy would be a judicial option because all initial goals have been achieved. The absence of medication adverse effects and improvement in patient symptoms showed the achievement of the initial goals of care. ‘

Ethical Considerations

A further dose increase may have no clinical value to patient care but risk adverse effects such as gastrointestinal systems nausea, vomiting, and insomnia. According to Wang et al. (2022), Paxil, as opposed to other SSRIs, has poorer gastrointestinal tolerability as compared with other medications such as escitalopram.

These adverse effects would be a reason for medication nonadherence and clinical deterioration. Suicidality and other adverse events would pose more harm to the patient than good. Therefore, the principle of beneficence still dominated my clinical decision-making.

Conclusion

The patient in this case scenario had severe anxiety, as shown by the HAM-A score of 26. He was diagnosed with a generalized anxiety disorder (GAD), and other medical diagnoses, such as MI, were excluded at the ER. My first clinical decision was to start the patient on Paxil 10mg OD, which proved beneficial because the patient presented four weeks later with symptom reduction and a HAM-A score of 18.

The second decision after this partial response was to increase the Paxil dose rather than switch to other SSRIs such as Prozac. This dose increment was expected to cause further symptom reduction and improvement in the HAM-A score. The outcomes were a HAM-A score of 10 and further symptom reduction with no other significant adverse effect reported.

Therefore, the last decision was to maintain the Paxil dose and 20mg daily because all goals had been achieved. Further dose increments could risk suicidality and other adverse effects such as nausea and vomiting. Ethically, I believe that my decisions upheld beneficence and non-maleficence principles.

References

  • Currow, D. C., Ekström, M., Louw, S., Hill, J., Fazekas, B., Clark, K., Davidson, P. M., McDonald, C., Sajkov, D., McCaffrey, N., Doogue, M., Abernethy, A. P., & Agar, M. (2019). Sertraline in symptomatic chronic breathlessness: a double-blind, randomized trial. The European Respiratory Journal: Official Journal of the European Society for Clinical Respiratory Physiology53(1), 1801270. https://doi.org/10.1183/13993003.01270-2018
  • David, P. S., Smith, T. L., Nordhues, H. C., & Kling, J. M. (2022). A clinical review on paroxetine and emerging therapies for the treatment of vasomotor symptoms. International Journal of Women’s Health14, 353–361. https://doi.org/10.2147/IJWH.S282396
  • Jin, Q., Li, J., Chen, G.-Y., Wu, Z.-Y., Liu, X.-Y., Liu, Y., Chen, L., Wu, X.-Y., Liu, Y., Zhao, X., & Song, Y.-H. (2022). Network and experimental pharmacology to decode the action of Wendan Decoction against Generalized Anxiety Disorder. Drug Design, Development, and Therapy16, 3297–3314. https://doi.org/10.2147/DDDT.S367871
  • Kleinsinger, F. (2018). The unmet challenge of medication nonadherence. The Permanente Journal22(3). https://doi.org/10.7812/tpp/18-033
  • Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert Opinion on Pharmacotherapy19(10), 1057–1070. https://doi.org/10.1080/14656566.2018.1491966
  • Wang, Z., Li, H., Kang, Y., Liu, Y., Shan, L., & Wang, F. (2022). Risks of digestive system side-effects of selective serotonin reuptake inhibitors in patients with depression: A network meta-analysis. Therapeutics and Clinical Risk Management18, 799–812. https://doi.org/10.2147/TCRM.S363404
  • Zhang, B., Wang, C., Cui, L., Gao, J., Wang, C., Tan, X., & Fang, S. (2020). Short-term efficacy and tolerability of paroxetine versus placebo for panic disorder: A meta-analysis of randomized controlled trials. Frontiers in Pharmacology11, 275. https://doi.org/10.3389/fphar.2020.00275

Assignment Instructions

Assessing and Treating Patients With Anxiety Disorders

Common symptoms of anxiety disorders include chest pains, shortness of breath, and other physical symptoms that may be mistaken for a heart attack or other physical ailment. These manifestations often prompt patients to seek care from their primary care providers or emergency departments.

Once it is determined that there is no organic basis for these symptoms, patients are typically referred to a psychiatric mental health practitioner for anxiolytic therapy. For this Assignment, as you examine the patient case study in this week’s Learning Resources, consider how you might assess and treat patients presenting with anxiety disorders.

To prepare for this Assignment:

Review this week’s Learning Resources, including the Medication Resources indicated for this week.
Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients requiring anxiolytic therapy.

The Assignment: 5 pages

Examine Case Study: A Middle-Aged Caucasian Man With Anxiety. 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.

BACKGROUND INFORMATION

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 feeling of impending doom.

He does have some mild hypertension (which is treated with 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. Remainder of physical exam was WNL.

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 to “run” or “escape” from wherever he is at.

In your office, he confesses to occasional use of ETOH to combat worries about work. He admits to consuming about 3-4 beers/night. Although he is single, he is attempting to care for aging parents in his home. He reports that the management at his place of employment is harsh, and he fears for his job. You administer the HAM-A, which yields a score of 26.

Client has never been on any type of psychotropic medication.

MENTAL STATUS EXAM

The client is alert, oriented to person, place, time, and event. He is appropriately dressed. Speech is clear, coherent, and goal-directed. Client’s self-reported mood is “bleh” and he does endorse feeling “nervous”. Affect is somewhat blunted, but does brighten several times throughout the clinical interview. Affect broad. Client denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, as is insight. He denies suicidal or homicidal ideation.

You administer the Hamilton Anxiety Rating Scale (HAM-A) which yields a score of 26.

Diagnosis: Generalized anxiety disorder

RESOURCES

  • Hamilton, M. (1959). Hamilton Anxiety Rating Scale. Psyctests, doi:10.1037/t02824-0

Decision point one: Begin Paxil 10 mg po daily

RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks

Client informs you that he has no tightness in chest, or shortness of breath

Client states that he noticed decreased worries about work over the past 4 or 5 days

HAM-A score has decreased to 18 (partial response)

Decision point two: Increase Paxil dose to 20 mg po daily

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks

Client reports an even further reduction in his symptoms

HAM-A score has now decreased to 10. At this point- continue current dose (61% reduction in symptoms)

Decision point three:

Maintain current dose

Guidance to Student
At this point, it may be appropriate to continue client at the current dose. It is clear that the client is having a good response (as evidenced by greater than a 50% reduction in symptoms) and the client is currently not experiencing any side effects, the current dose can be maintained for 12 weeks to evaluate full effect of drug.

Increasing drug at this point may yield a further decrease in symptoms, but may also increase the risk of side effects. This is a decision that you should discuss with the client. Nothing in the client’s case tells us that we should consider adding an augmentation agent at this point as the client is demonstrating response to the drug. Avoid polypharmacy unless symptoms cannot be managed by a single drug.

Grading Rubric

  ExcellentPoint range: 90–100 GoodPoint range: 80–89 FairPoint range: 70–79 PoorPoint range: 0–69
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. 9 (9%) – 10 (10%)The response accurately, clearly, and fully summarizes in detail the case for the Assignment.The response accurately and clearly explains in detail the specific patient factors that impact decision making when prescribing medication for this patient. 8 (8%) – 8 (8%)The response accurately summarizes the case for the Assignment.The response accurately explains the specific patient factors that impact decision making with prescribing medication for this patient. 7 (7%) – 7 (7%)The response inaccurately or vaguely summarizes the case for the Assignment.The response inaccurately or vaguely explains the specific patient factors that impact decision making with prescribing medication for this patient. 0 (0%) – 6 (6%)The response inaccurately and vaguely summarizes the case for the Assignment, or is missing.The response inaccurately and vaguely explains the specific patient factors that impact decision making with prescribing medication for this patient.
Decision #1 (1–2 pages)• 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.
18 (18%) – 20 (20%)The response accurately and clearly explains in detail the decision selected.The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected.

The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients.

Examples provided fully support the decisions and responses provided.

16 (16%) – 17 (17%)The response accurately explains the decision selected.The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected.

The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response.

The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response.

The response accurately explains how ethical considerations impact the treatment plan and communication with patients.

Examples provided support the decisions and responses provided.

14 (14%) – 15 (15%)The response inaccurately or vaguely explains the decision selected.The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected.

The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response.

The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response.

The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients.

Examples provided may support the decisions and responses provided.

0 (0%) – 13 (13%)The response inaccurately and vaguely explains the decision selected.The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing.

The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing.

The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing.

The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing.

Examples provided do not support the decisions and responses provided, or is missing.

Decision #2 (1–2 pages)• 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.
18 (18%) – 20 (20%)The response accurately and clearly explains in detail the decision selected.The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected.

The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients.

Examples provided fully support the decisions and responses provided.

16 (16%) – 17 (17%)The response accurately explains the decision selected.The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected.

The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response.

The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response.

The response accurately explains how ethical considerations impact the treatment plan and communication with patients.

Examples provided support the decisions and responses provided.

14 (14%) – 15 (15%)The response inaccurately or vaguely explains the decision selected.The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected.

The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response.

The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response.

The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients.

Examples provided may support the decisions and responses provided.

0 (0%) – 13 (13%)The response inaccurately and vaguely explains in detail the decision selected.The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing.

The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing.

The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing.

The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing.

Examples provided do not support the decisions and responses provided, or is missing.

Decision #3 (1–2 pages)• 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.
18 (18%) – 20 (20%)The response accurately and clearly explains in detail the decision selected.The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected.

The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients.

Examples provided fully support the decisions and responses provided.

16 (16%) – 17 (17%)The response accurately explains the decision selected.The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected.

The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response.

The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response.

The response accurately explains how ethical considerations impact the treatment plan and communication with patients.

Examples provided support the decisions and responses provided.

14 (14%) – 15 (15%)The response inaccurately or vaguely explains the decision selected.The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected.

The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response.

The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response.

The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients.

Examples provided may support the decisions and responses provided.

0 (0%) – 13 (13%)The response inaccurately and vaguely explains in detail the decision selected.The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing.

The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing.

The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing.

The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing.

Examples provided do not support the decisions and responses provided, or is missing.

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. 14 (14%) – 15 (15%)The response accurately and clearly summarizes in detail the recommendations on the treatment options selected for this patient.The response accurately and clearly explains a justification for the recommendations provided, including clinically relevant resources that fully support the recommendations provided. 12 (12%) – 13 (13%)The response accurately summarizes the recommendations on the treatment options selected for this patient.The response accurately explains a justification for the recommendation provided, including clinically relevant resources that support the recommendations provided. 11 (11%) – 11 (11%)The response inaccurately or vaguely summarizes the recommendations on the treatment options selected for this patient.The response inaccurately or vaguely explains a justification for the recommendations provided, including clinically relevant resources that inaccurately or vaguely support the recommendations provided. 0 (0%) – 10 (10%)The response inaccurately and vaguely summarizes the recommendations on the treatment options selected for this patient, or is missing.The response inaccurately and vaguely explains a justification for the recommendations provided, including clinically relevant resources that do not support the recommendations provided, or is missing.
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 (5%) – 5 (5%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity.A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. 4 (4%) – 4 (4%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.Purpose, introduction, and conclusion of the assignment are stated, yet they are brief and not descriptive. 3.5 (3.5%) – 3.5 (3.5%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time.Purpose, introduction, and conclusion of the assignment is vague or off topic. 0 (0%) – 3 (3%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time.No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation
5 (5%) – 5 (5%)Uses correct grammar, spelling, and punctuation with no errors. 4 (4%) – 4 (4%)Contains a few (1 or 2) grammar, spelling, and punctuation errors. 3.5 (3.5%) – 3.5 (3.5%)Contains several (3 or 4) grammar, spelling, and punctuation errors. 0 (0%) – 3 (3%)Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/ in-text citations, and reference list. 5 (5%) – 5 (5%)Uses correct APA format with no errors. 4 (4%) – 4 (4%)Contains a few (1 or 2) APA format errors. 3.5 (3.5%) – 3.5 (3.5%)Contains several (3 or 4) APA format errors. 0 (0%) – 3 (3%)Contains many (≥ 5) APA format errors.