Fluent Essays

file attached below. Please please follow the directions. It’s a DB response. Peer review articles within 5 years of publications. Feel free to contact me. T db_1_reply_2020.docx Unformatted Attachment Preview DB1: Reply 250 words peer review articles within 5 years of publication only USA (2-3references) What is your diagnosis? Describe how this chain of events may have led to the overall clinical picture. DX: Major Depressive Disorder moderate to severe (Association, 2013). Adjustment Disorder due to the distress that is out of proportion to the severity of the stressor manifested by functional impairment (Dulcan, Ballard, Jha, & Sadhu, 2018). He is experiencing Major Depressive Disorder, as evidenced by his depressed mood most of the day, irritable, his social isolation, a lack of interest in regular activities, hypersomnia, and suicidal ideation vague with no plan. This young man was recently cut from the football team which equated to a major loss. There is no mention of the precipitating circumstances as to why he was cut. There is no mention of any other factors such as social, academics, home life that could give insight to his behavior. His lost interest in most social activities and he has been secluding himself in his room sleeping and eating and has become more irritable and lethargic. He is missing school. Also, researchers have contended that depression may be genetically based and predisposes individuals to develop depression (Keltner & Steele, 2019). The client has a maternal aunt with Bipolar. Why is this particular blood work significant? If this were a female what additional blood work would be necessary and why? CBC to rule out anemia or other disorders which could contribute to excessive fatigue (Daniels, 2015), ALT is elevated but insignificant. BMI 35 doesn’t give much information of height and weight and he is a football player which may include muscle mass. His fasting glucose was moderately elevated and slightly elevated HBA1c may be indicative of prediabetes (Daniels, 2015). This test will be retested in 3 months (Daniels, 2015). Remember that he has not been active, and his eating habits may have changed. It states that he eats and sleeps frequently, and the time wasn’t specified. If this were a female what additional blood work would be necessary and why? A urine pregnancy test to rule out pregnancy. In both males and females, I would check thyroid function. Thyroid function studies (triiodothyronine [T3], thyroxine [T4], thyroid stimulating hormone [TSH]). Urine drug test, serum B12 and folate, and vitamin D. Testing for infectious diseases, such as hepatitis C or HIV, if applicable. What medication and lifestyle modifications would you try first? This client has suicidal ideation no plan and without intent. He will be treated on an outpatient basis with close follow-up. Crisis intervention immediately (Dulcan, Ballard, Jha, & Sadhu, 2018). He appears to have a good social support (his mother). The mother will be advised to remove weapons from the environment if applicable. He will have a follow-up visit within 1-2 weeks (Keltner & Steele, 2019). Due to the severity of his depression the American Academy of Child and Adolescent Psychiatry’s practice parameters and the Guidelines for Adolescent Depression in Primary Care (GLAD-PC guidelines recommend either specific psychotherapies, medication, or combination (Depression in Children, 2020). Escitalopram 10mg daily would be the drug of choice (Depression in Children, 2020). Individual psychotherapy cognitive behavior therapy (CBT) as well as group therapy would allow him the opportunity to express his feelings as well as hear other individuals that may be experiencing the same feelings and provide solutions to help him through this hard time (Wheeler, 2014). Lifestyle modification would include becoming more active and engaged with school and activities. References Association, A. P. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington DC. Daniels, R. (2015). Guide to Laboratory and Diagnostic Test. Ashland: Delmar Publication. Depression in Children. (2020, Jan 13). Retrieved from epocrates.com: https://online.epocrates.com/diseases/78534/Depression-in-children/Diagnostic-TestDetails Dulcan, M. K., Ballard, R. R., Jha, P., & Sadhu, J. M. (2018). Concise Guide to Child & Adolescent Psychiatry. Arlington: American Psychiatric Association. Keltner, N. L., & Steele, D. (2019). Psychiatric Nursing. St. Louis: Elsevier. Klykylo, W. M., Bowers, R., Weston, C., & Jackson, J. (2014). Greens Child & Adolescent Clincal Psychopharmacology. Philadephia: Wolters Kluwer. Wheeler, K. (2014). Psychotherapy for the Advanced Practice Psychiatric Nurse. A How-To Guide for Evidence-Based Practice. New York: Springer Publishing Company. Hilda is a 48-year-old woman Diagnosis: Insomnia Disorder Differential Diagnosis (Association, 2013): Narcolepsy, normal sleep variations, delayed sleep phase and shift work types of circadian rhythm sleep-wake disorder, breathing-related sleep disorder, parasomnias or substance/medication-induced sleep disorder, insomnia type Treatment Plan: History and physical examination with focus on ruling out any thyroid disease, anxiety, drug interactions, or substance abuse. What medication is she taking prescribed or over the counter? Laboratory studies would include (Rhoads & Murphy, 2015): Thyroid function studies (triiodothyronine [T3], thyroxine [T4], thyroid-stimulating hormone [TSH]) Complete metabolic panel (CMP), including glucose, calcium, and albumin; total protein analysis; and levels of sodium, potassium, CO2 (carbon dioxide, bicarbonate), chloride, blood urea nitrogen (BUN), creatinine, alkaline phosphatase (ALP), alanine amino transferase (ALT, also called SGPT), aspartate amino transferase (AST, also called SGOT), and bilirubin Complete blood count (CBC) with differentials: hemoglobin, hematocrit, red blood cell (RBC) count, white blood cell (WBC) count, WBC differential count, and platelet count. UCG and UDS (Rhoads & Murphy, 2015). Diagnostic exam would recommend a CT head as well as a sleep study. CT head to rule out any brain anomalies and the sleep study to rule out and obstructive/nonobstructive sleep disorders. Short-term use of non-BZD medications: Adult treatment only first-line therapy would include: Eszopiclone (Lunesta), Zaleplon (Sonata), Zolpidem (Ambien, Ambien CR, Edluar, Intermezzo, Zolpimist), or Ramelteon (Rozerem) (Rhoads & Murphy, 2015). A sleep diary should be initiated to have a tangible data to analyze. Continue to avoid caffeine 6 hours before sleep, avoid exercise 4 hours before sleep (Rhoads & Murphy, 2015). Avoid diet high in protein or alcohol 3 to 6 hours before sleep. Create a calm, cool, quiet atmosphere for sleep. Avoid napping. Using the bed for sleeping and sex only (Rhoads & Murphy, 2015). If unable to sleep for 30 minutes, engage in a quiet activity, such as light reading or listening to music (Rhoads & Murphy, 2015). Consider psychiatric evaluation if mental, emotional, or behavioral disorder per her report that the onset was post her divorce and has persist and she states that her mind keeps going over “things”. There are a lot of important information missing from this case study. Does she have mental health history or familiar history. Does she live in the city or rural area? Does she have any medical problems history of drug use? There are many concerns regarding her operating a car while falling asleep. Also, is there some underline feelings that she has not confronted surrounding her divorce. Bibliography Association, A. P. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington DC. Daniels, R. (2015). Guide to Laboratory and Diagnostic Test. Ashland: Delmar Publication. Keltner, N. L., & Steele, D. (2019). Psychiatric Nursing. St. Louis: Elsevier. Rhoads, J., & Murphy, P. J. (2015). Clinical Consult to Psychiatric Nursing for Advanced Practice. New York: Springer Publishing Company, LLC . Wheeler, K. (2014). Psychotherapy for the Advanced Practice Psychiatric Nurse. A How-To Guide for Evidence-Based Practice. New York: Springer Publishing Company. DB 2: Reply 250 words peer review articles within 5 years of publication only USA (2-3references) A 15 year old boy is brought in for an evaluation. Parents state that over the last several months his has become more irritable, lethargic and apathetic towards his academics and home life in general. Parents state that ever since he was cut from the football team he has lost interest in most social activities and spends all his free time secluding himself in his room sleeping and eating. No matter how many hours of sleep he achieves he chronically complains of lethargy and his mother states “it looks like he wrestles snakes in his bed at night”. They are concerned that if he misses anymore school he will not graduate on time. Family History: Father known to have anxiety. Maternal aunt known to have Bipolar disorder 2 Surgical History: Tonsilectomy and adenoids age 7. Physical Exam: 15 year old white male in no acute distress. Dress is appropriate for stated age and season. BMI is 35. HEENT: Thyroid nonpalpable due to body habitus, all other systems normal. Lungs clear. Heart RRR, S1 and S2 normal with no rubs or murmurs. Abdomen soft, no bruit or HSM. Extremities normal. Lab work: CBC Normal, Comprehensive panel normal except ALT is mildly elevated. Glucose is 110, HA1C is 6.2 and fasting insulin level is 35, moderately elevated Alert and Oriented to person, place and time. Speech presents with clear articulation and soft in volume. Mood is deflated, affect congruent. Thought process is logical linear and concise. Denies auditory or visual hallucinations. Suicidal ideation is present with no plan. Fleeting thoughts of “just disappearing” and feeling like a failure. What is your diagnosis? Describe how this chain of events may have led to the overall clinical picture. The diagnoses of Major Depressive Disorder (MDD) is supported by the presence of irritability, lethargy and apathy that was of several month duration. There was the presence of sleep disturbance that was evidenced by the mother’s account of his sleep and the lethargy regardless of the amount of sleep he achieved; The onset of the depression was noted to start after he was cut from the football team and lead to a loss of interest in social activities and seclusion. There was disturbance in his school functioning. While there was a family history of anxiety and bipolar disorder, type 2, there was no evidence of mania or an anxious component. He presented with a deflated mood. He denied auditory or visual hallucinations and did report suicidal ideation without a plan. A key indicator of depression in young people includes declining school performance, withdrawal from socialization, and sleep disturbances; Adolescents may present as irritable or sad (Dulcan, et al, 2018). The loss of participation on the football team appears to be the major precipitating event; According to Keltner & Steele (2019), loss is a major component of stress and can lead to dysfunction in interpersonal relationships. Stress is a major cause of depression. The sense of loss and of being a failure led to social isolation and eating in his room. While a baseline weight or BMI was not provided, the lack of activity and eating in isolation could have contributed to the obesity and abnormal ALT and fasting insulin levels. Why is this particular blood work significant? If this were a female what additional blood work would be necessary and why? A common cause of elevated ALT is nonalcoholic fatty liver disease (NAFLD). Adopting a low fat, moderate carbohydrate diet that is rich in fresh fruits and vegetables is effective in treatment and prevention of NAFLD (Santos-Longhurst, 2018). The moderately elevated fasting insulin level and the BMI of 35 provide evidence of insulin resistance and metabolic dysfunction. According to Webb, et al (2017), symptoms of depression was associated with metabolic dysfunction and represented an increased risk for Diabetes Mellitus, type 2, CVD and inflammation. For a female, an oral glucose tolerance test, and lipid profile, especially triglyceride levels would be needed to evaluate for the risk of diabetes and CVD. With the increased incidence of PCOS in females with metabolic disorders, monitoring for PCOS would be needed (Webb, et al, 2017). What medication and lifestyle modifications would you try first? Close parental and psychiatric supervision would be needed when suicidal ideation is present, whether there is a plan or not. Individual and family therapy has been found to be beneficial to provide psychoeducation regarding information about depression treatment and recognition of symptoms of relapse. While psychotherapy is considered the first-line treatment, medications may be added if symptoms do not improve in 4-6 weeks or are of a severity to mandate their use. Fluoxetine and escitalopram are approved for treatment of pediatric MDD. SSRIs do carry a black box warning regarding the risk of suicidal thinking and behaviors (Dulcan, et al, 2018). Due to the presence of obesity and elevated fasting insulin and ALT, exercise and a low fat, moderate carbohydrate diet would be initiated (Santos-Longhurst, 2018). References Dulcan, M.K., Ballard, R.R., Jha, P., & Sadhu, J.M., 2018. Concise Guide to Child & Adolescent Psychiatry. 5th edition. Arlington, VA: American Psychiatric Association Publishing. Keltner, N.L., & Steele, D., 2019. Psychiatric Nursing. 8th edition. St. Louis, MO: Elsevier. Santos-Longhurst, A., 2018. How to Lower ALT Levels. Healthline.com, November 27, 2018. Retrieved from https://healthline.com on 1/14/2020. Webb, M., Davies, M., Ashra, N., Bodicoat, D., Brady, E., Webb, D., Moulton, C., Ismail, K., Khunti, K, 2017. The Association between Depressive Symptoms and Insulin Resistance, Inflammation, and Adiposity in Men and Women. PloSOne. 2017 Nov 30, 12(11); e0187448. doi: 10.1371/journal.pone.0187448. Retrieved on 1/14/2020. Hilda is a 48 year old woman who presents to a GP complaining of feeling exhausted and not being able to concentrate. She says she has a long history of poor sleep patterns that started almost 15 years ago when her first marriage broke up. Currently, she wakes 4 to 6 times every night and often cannot get back to sleep for up to 2 hours. She reports that her mind keeps going over “things”. She says she gets 2 to 3 hours of „good‟ sleep when she first goes to bed but then wakes between 1am and 2am and then gets only very broken sleep. Hilda says she has begun to dread going to bed. Hilda says she has tried yoga, herbal remedies, eliminating coffee and alcohol, massage and acupuncture and that they worked for a while but eventually she returned to her broken sleep patterns. She says she is just exhausted and fed up with the situation. She is considering stopping driving because she is so tired through the day. Hilda does not seem to be depressed but is clearly worried about not sleeping. There are no underlying medical conditions. The GP decides to refer Hilda to you. Discuss your diagnosis, the differential diagnosis and make a treatment plan. Discuss your thoughts on this case. My diagnosis for Hilda would be Insomnia Disorder (ID), Persistent. According to Morrison (2014), ID is characterized by trouble getting to sleep, staying asleep, or awaking too early. There must be distress or disability related to the difficulty sleeping. ID is more common in older adults and women. Hilda meets these characteristics with her 15 year history of poor sleep patterns that leaves her feeling exhausted, unable to concentrate, and fearful of driving. She reportedly does not appear depressed and has no underlying medical condition. Since Hilda reports having tried yoga, herbal remedies, eliminating coffee and alcohol, massage, and acupuncture, a review of sleep habits to evaluate sleep hygiene would be beneficial. Melatonin has been shown to be effective in the treatment of persons with insomnia as a general sleep-promoting factor (Keltner & Steele, 2019). Zolipidem provides sleep promoting effects and has a better safety profile and less tolerance over the long term than the use of benzodiazepines (Monti, et al, 2017). Differential diagnosis would be substance use, other physical disorders, mood and anxiety disorders, other sleep-wake disorders, poor sleep hygiene, and too little available sleep time (Morrison, 2014). While the information indicated that there were no underlying health conditions, possible causes would need to be evaluated. I learned a long time ago to never assume that any person was not a substance abuser. She did not report any evidence of an anxious component but mood disorder would need to be evaluated and ruled out. Sleep habits and evaluation of sleep hygiene would be crucial. References Keltner, N.L., & Steele, D., 2019. Psychiatric Nursing. 8th edition. St. Louis, MO: Elsevier. Monti, J.M., Spence, D.W., Buttoo, K., & Pondi-Perual, S.R., 2017. Zolpidem’s Use for Insomnia. Asian Journal of Psychiatry, Volume 25, February 2017, pp 79-90. Retrieved from https://sciencedirect.com on 1/14/2020. Morrison, J., 2014. DSM-5 Made Easy: The Clinician’s Guide to Diagnosis. New York, NY: The Guilford Press. DB 3 Reply: Reply 250 words peer review articles within 5 years of publication only USA (23references) Bipolar Disorder is a chronic mental illness with Bipolar I being the most significant of all the bipolar. The patient experiences mood swings between manic episodes and major depression. The patient cycles through mood episodes in one year presents with melancholic features- loss of pleasure in all or almost all activities may have psychotic features- delusion or hallucinations, Anxiety distress – feeling keyed up, difficulty concentrating. The DSM-V criteria for Bipolar I require a distinctive period of abnormal mood lasting at least one week and includes separate bipolar I Disorder diagnosis for a single manic episode and recurrent episodes (Sadock, Sadock, & Ruiz, 2017). For an episode of mania to be considered manic, the mood disturbance must cause marked impairment in social, occupational functioning, resulting in hospitalization or involve psychotic features that cannot be attributed to the effects of drugs, medications, or any other medical condition (Covino & Hoffman, 2019). Bipolar affects men and women the same and can occur at any age; however, it is frequently seen in Bipolar I at a mean age of 18.2 and 20.3 for Bipolar II (Covino & Hoffman, 2019). The prevalence of Bipolar II in children is difficult to establish but the diagnosis is usually at the age of 12 years or older (DSM-V). Bipolar II Disorder- is similar to Bipolar I, with the exception that the patient may never experience a manic episode; they are usually hypomanic. Bipolar II has a higher incidence in Females (Keltner & Steele, 2019). The diagnostic criteria for Bipolar II specify the severity, frequency, and duration of hypomania (Sadock, Sadock & Ruiz, 2017). Etiology of Bipolar Disorder: Biological and Genetic factor plays a role; one-third of first-degree relatives with bipolar spectrum disorder have symptoms of bipolar spectrum disorder (Dulcan et al., 2018). -Environmental factors such as physical abuse, negative parenting styles, poor social support, prenatal alcohol exposure Bipolar disorder is frequently comorbid with ADHD, ODD, conduct disorder, substance, and alcohol use disorder in children. Case study Diagnosis: Bipolar Disorder II, current episode hypomanic with mixed featuresThis diagnosis is based on Criteria A in DSM-V- which is characterized by recurring mood episodes of at least one hypomanic episode, which must last four days or more, and one or more major depressive episodes, which lasts at least two weeks (DSM-V). The clinical features of Bipolar II Disorder are those of major depressive disorder combined with hypomanic episodes (Sadock, Sadock & Ruiz, 2015). What information is missing would be helpful when lookin ... 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