Case Studies
Jason is a cocaine addict. He last used approximately an hour ago. He is experiencing persecutory hallucinations, nausea, vomiting, psychomotor agitation, tachycardia, muscle weakness, etc. What would be an appropriate diagnosis for Jason?
What would be the antidote?
Stimulant intoxication is the correct diagnosis: stimulants tend to cause persecutory hallucinations, mydriasis, psychomotor agitation or retardation, dangerous sexual behavior, aggression, tachycardia or bradycardia, perspiration or chills, cardiac arrhythmias, dyskinesias, N&V, respiratory depression, muscle weakness, etc. Stimulant withdrawal usually peaks in 2-4 days and is done by one week. Can have a stimulant induced psychosis which can include paranoid (or persecutory) and auditory hallucinations. In addition cocaine can cause the sensation of bugs crawling beneath the skin (formication). Treatment for the psychosis can involve haloperidol. However there is no antidote or effective pharmacotherapy for stimulant abuse/use. Generally psychosocial therapies can be useful including network therapy to involve patient’s family and peers. Detox is usually done outpatient, major hurdle is cravings.
Rosa, presents to the PMHNP office for a complaint of sleeping issues. She is 6 years old and has been diagnosed with mild Intellectual disability (Intellectual Developmental Disorder).
Answer the following questions:
When is the diagnosis of intellectual impairment usually identified?
What law prevents the term mental retardation?
What IQ level would Rosa have in order to receive a classification of Mild Intellectual Disability?
Before you start meds what would you ask?
What medication would you start with?
1.Intellectual impairment is usually identified within the first 2 years of life.
2.Rosa’s Law
3.Mild IQ level is 52-69
4.Ask about electronics, how they get ready for bed, etc.
5.Melatonin is a good start
AUDIT (Alcohol Use Disorders Identification Test)
AUDIT (Alcohol Use Disorders Identification Test) It is a 10-item screening tool used to assess alcohol consumption, behaviors, and problems associated with alcohol use. Ut was developed by the World Health Organization (WHO). There is a clinician-administered version and a self-report version. Patients are encouraged to answer the AUDIT questions in terms of standard drinks. There is a chart included which illustrates the approximately number of standard drinks in different alcohol beverages for reference. A score of 8 or more is considered to indicate a hazardous or harmful alcohol use.
A client presents to the clinic for treatment of substance use disorder. The PMHNP is going to schedule the client with a provider who specializes in memory reconsolidation treatment. Which of the following treatments are considered this type of treatment?
Eye movement desensitization and reprocessing
Cognitive behavioral therapy
Buprenorphine treatment
Psychoanalytic treatment
Eye movement desensitization and reprocessing
From the psychotherapies for addiction ppt:
Mary is experiencing alcohol withdrawal. Out of the list of symptoms below, which one is not considered a part of alcohol withdrawal?
Dry skin
Nausea and vomiting
Transient hallucinations
Seizures
Dry skin
Review DSM-5-TR, Kaplan & Sadock textbook, or SUD PPT for alcohol withdrawal. Symptoms include: autonomic hyperactivity (sweating, tachycardia, etc.), increased hand tremor, insomnia, nausea and vomiting, transient hallucinations or illusions, psychomotor agitation, anxiety, and generalized tonic-clonic seizures.
Sam has been diagnosed with Wernicke-Korsakoff syndrome and has nystagmus, ataxia, paralysis of ocular muscles, confusion, apathy, and somnolence. In addition he struggles a great deal with retentive memory.
Besides Wernicke-Korsakoff syndrome what would be another diagnosis for Sam?
What is the most common defense mechanism that Sam might utilize?
How would you treat the Wernicke-Korsakoff syndrome?
If he was in Alcohol Withdrawal, what scale could be utilized to assess and manage his alcohol withdrawal symptoms.
Another diagnosis would be the following: Alcohol Use Disorder and more than likely Severe (need presence of six or more symptoms such as craving, taken in larger amounts, unsuccessful attempts to cut down, great deal of time spent in getting or ingesting alcohol, failed obligations, hazardous drinking situations, tolerance, etc.
Most common defense mechanism for most substance abusers is denial.
You would treat Wernicke-Korsakoff syndrome with thiamine supplementation (100 mg oral 2-3 times a day for 3-12 months). The symptoms are generally caused by a thiamine deficiency.
Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWAS-Ar) is a 10-item scale used in the assessment and management of alcohol withdrawal. The CIWAS was the original 15 item scale. Scores of 8 or greater require treatment for withdrawal symptoms. Diazepam is the most commonly prescribed benzodiazepine for the treatment of alcohol withdrawal. Treatment is generally initiated with a score of greater than 8. Ativan is a common treatment as well. Generally use the revised scale or CIWAS-Ar. High scores not only provide an indication of severe withdrawal but are also predictive of the development of seizures and delirium.
CIWA is 15 items and the CIWA-AR is 10 items
§A newborn infant is being examined in the hospital. The NP suspects Down’s Syndrome. Which of the following physical characteristics would not be a part of Down’s Syndrome?
A. Oblique Palpebral Eyelids
B. Hypertonia
C. Singla Palmar transversal crease
D. Short fingers
(Answer B). Most common is Down’s syndrome: characteristic physical attributes of slanted eyes, epicanthal folds, and a flat nose.. As infants there is general hypotonia, oblique palpebral (eyelids) fissures, abundant neck skin, a small flattened skull; high cheekbones and a protruding tongue. Hands are broad and thick with a single palmar transversal crease with short fingers which curve inward. Motor reflexes are weak or absent. Often have physical growth problems, cardiac defects, thyroid abnormalities and GI problems. Life expectancy is often limited to about age 40.
Hypertonia in a newborn infant can be due to chemical exposure, brain developmental injury, lack of oxygen during birth.
K.C. has come into the outpatient clinic and the PMHNP is going to screen for drug abused or dependence disorders. Which of the following screening tools would be an effective means to screen?
A. PHQ-9
B. GAD-7
C. DAST
D. MMSE
Answer is C: DAST or Drug Abuse Screening Test
The PHQ-9 is to screen for depression
GAD-7 is to screen for anxiety
MMSE is a screening tool for dementia
According to the DSM-5-TR criteria, what is the maximum age threshold for symptom onset when making a diagnosis of attention deficit hyperactivity disorder (ADHD)?
5
7
12
15
12
12 is the correct answer. In the DSM-5-TR the maximum age threshold for symptom onset for diagnosing ADHD is 12 years of age.
Miriam has been admitted to the hospital for two days with alcohol withdrawal. She has a history of drinking a pint of vodka and two bottles of wine a day for over 20 years.
What is a particular concern at this time?
What would be the symptoms you should look for?
How would you prevent?
Delirium tremens typically occurs in a client with a history of heavy drinking. The symptoms usually occur 2-5 days after quitting drinking and can last around 2-3 days. Triad of symptoms include: elevated temperature, tremors and tachycardia, accompanied by cognitive changes. Prevention of DTs can be with the use of benzodiazepines but studies have also shown that carbamazepine in daily doses of 800 mg is as effective of benzos with the added benefit of minimal abuse liability, as well as not having to worry about respiratory depression. Best treatment for DTs is prevention because no one treatment is the answer. May start at chlordiazepoxide (Librium) given orally 50-100 mg every 4 hours or lorazepam given IV if oral not possible. IM is not recommended because of erratic absorption
Samuel, 7 year old male, presents to the PMHNP office for an evaluation of possible ADHD. Answer the following questions:
A. How many symptoms must he have in order to diagnose?
B. How long must be have this condition?
C. At what age must the symptoms present by?
D. What screening scales could you use to help in the diagnosis?
E. How would you treat?
§F. What would be a known risk fact in which stimulants would be avoided?
A.Must have 6 symptoms because he is less than 17 YOA.
B.Must have symptoms for at least six months
C.Must present by age 12
D.Vanderbilt scale is a common scale used, most teachers are familiar with this as well. You may use this scale for ages 6-12 YOA. You would not use this scale for adults.
E.Often start with Intuniv ER if there is a lot of hyperactivity and impulsivity. If more inattentive, may try as well or even Strattera (watch for priapism because he is a male). Stimulants are an option as well. Therapy can be useful from a behavioral management standpoint.
Cardiac risks and abnormalities
DAST-10
DAST-10 is a shortened version of a previous 28 item drug abuse screening tool. It can be self-report or interview format. Can be used in a variety of settings as a quick index of drug abuse problems.
Scores of 1-2 low level concern
Scores of 3-5 Moderate level concern
Scores of 6-8 Substantial level of concern
Scores of 9-10 Severe level of concern
A 4-year-old client comes to the clinic after significant testing for learning problems. The client was found to have an IQ of 60. What would be the appropriate diagnosis for this client?
Borderline intellectual impairment
Mild intellectual impairment
Moderate intellectual impairment
Severe intellectual impairment
Correct Answer Mild intellectual impairment
An IQ of 60 means this client has Mild Intellectual Impairment (IQ 50-70). Borderline was used in the past for an IQ of 70-80 but is no longer used per DSM-5-TR. Moderate impairment (IQ 35-50) and Severe impairment (IQ 20-35). See PowerPoint and Kaplan & Saddock book for additional information.
Although the push is to step away from using IQ level to activities of daily living, etc. that the person is able to perform. In other words, the functional ability of the person. However, you will still see some sources use IQ levels as part of the functional assessment of clients.
Ezekiel injured his back several years ago. He finds himself in trouble because of going to obtain fentanyl from a dealer. He has developed __________ to fentanyl. Because he has developed a ____________, Ezekiel finds himself needing a higher dose than previously to help his pain. When he did not receive any Fentanyl in a long time, he began to experience __________ ____________. What assessment tool can be utilized to measure his level of response during withdrawal?
He has developed a behavioral, physiological and psychological dependence (dependence) to fentanyl. Discontinuing his use would cause adverse consequences and significant distress. While the term addiction is still used to usually denote the most severe forms of dependence/substance use disorder, the term addiction is not diagnostic and was omitted from the DSM-5 and continues to be omitted in the DSM-5-TR. The expectation from a diagnostic standpoint is to utilize the SUD and then indicate the severity level.
Tolerance: need more to achieve the desired effect or reduced effect from the usual dose).
Opiate Withdrawal due to not having fentanyl (a synthetic opiate). Opioid Withdrawal Syndrome is associated with severe muscle cramps and bone aches, profuse diarrhea, abdominal cramps, rhinorrhea, lacrimation, piloerection, yawning, fever, pupillary dilation (mydriasis), hypertension, tachycardia, and temperature dysregulation.
The Clinical Opiate Withdrawal Scale (COWS) is used to measure a client’s level of response. It is used for Buprenorphine/naloxone induction. Enter the scores at time zero, 1-2 hours after first dose, and at additional times when buprenorphine/naloxone is given over the induction period. COWS is used as a common method of assessing opiate withdrawal levels in patients who are in a residential treatment setting as well as those who are being monitored for medication assisted opiate addiction treatment. Eleven areas are graded: resting pulse rate, sweating, restlessness, pupil size, bone or joint aches, runny nose or tearing, GI upset, tremor, yawning, anxiety or irritability, and Gooseflesh skin.
Scoring for COWS: 5-12 Mild, 13-24 Moderate, 25-36 moderately severe, and more than 36 severe withdrawal. Treatment is initiated for scores Greater than or equal to 7.
Tuwanna is a 4 year old little girl who presents to the ER. When the nurse enters the room to examine the little girl, Tuwanna goes to the nurse (who she has never met) and hugs her tightly and won’t let go.
A. Is this usual behavior?
B. What should you look for?
C. What possible diagnosis?
A.Unusual behavior for children to actively approach and interact with unfamiliar adults.
B.Look at the caregiver-child relationship. Needs to make sure there is not abuse.
C.Disinhibited Social Engagement Disroder may be the diagnosis. Begins before the age of 5 and is present for more than 12 months. First consideration is safety of the child.
Older adults, age 50 and greater can present some unique challenges when providing treatment for substance use disorders. Which statement is false regarding the treatment of older adults with substance use disorders?
There is increased sensitivity to psychoactive drugs.
Often have co-existing medical or psychiatric disorders.
Generally, they have fewer legal problems and remain in treatment longer.
Providers regularly screen for substance use disorders in this population
Providers regularly screen for substance use disorders in this population.
From the psychotherapies with substance use disorder PPT:
When developing an education plan for a group of homeless patients with alcohol use disorder, the most important information to include is probably information about:
community resources
inpatient facilities
personal responsibility
medication to control alchol use
community resources
Information about community resources is the most important, including shelters, food banks, free meals, free clinics, and self-help groups, such as AA. Inpatient care is often an unrealistic goal.
When working with children and adolescents in a group setting what would be some considerations to make?
The age of children and developmental level is very important to consider when determining a group size for therapy with children. In addition, the therapist's ability to work with and tolerate a certain number of children should be considered. Neutrality is important to consider because the therapist does not want to side with the child against the parent and vice versa. It is always a good idea to get written consent from parents, regardless if required in the state or not.
K.C. has come into the outpatient clinic and the PMHNP is going to screen for alcohol use. Which of the following screening tools is utilized to screen for the use of alcohol?
A. AUDIT
B. CIWAS
C. COWS
D. PANSS
A.AUDIT (Alcohol Use Disorders Identification Test is the correct answer to screen for use. It is a 10-item screening tool used to assess alcohol consumption, behaviors, and problems associated with alcohol use.
●
The CIWAS (Clinical Institute Withdrawal Assessment of Alcohol Scale) is used for alcohol withdrawal not to screen for use.
The COWS (Clinical Opiate Withdrawal Scale) is used for withdrawal from opiates.
The PANSS (Positive and Negative Syndrome Scale) is used to measure symptom severity of patients with schizophrenia.
Jean Piaget describes different levels of thinking from a cognitive developmental standpoint. Which of the following statements is true regarding the cognitive developmental stages?
During the sensorimotor stage, thinking and reasoning become intuitive.
Stage of Formal operations occurs during the birth to 2 years of age time frame.
Concrete Operations a child is able to reason and follow rules and regulations and can begin to regulate themselves
Object Permanence is an important concept to grasp during the preoperative period.
Concrete Operations a child is able to reason and follow rules and regulations and can begin to regulate themselves
During the sensorimotor stage thinking is more primitive and not intuitive. Thinking becomes more intuitive during the preoperational thought period. The sensorimotor stage is between birth to two years of age. Preoperational thought is ages 2-7 years, concrete operation stage is ages 7-11 years and stage of formal operations is ages 11 through early adolescence. During the concrete operation stage, a child begins to realize the importance of following rules and become more adept at self-regulating their behavior. Object permanence is a concept which is usually grasped during the sensorimotor stage. This material is covered in the psychotherapies for children PPT, Wheeler textbook, and Kaplan & Sadock textbook under Jean Piaget.
Thomas is being treated for opioid withdrawal. Which medication can be useful to help with the anxiety, agitation, and muscle cramps which can accompany opioid withdrawal symptoms?
Clonidine
Olanzapine
Disulfiram
Bupropion
Clonidine
From the SUD ppt: Alpha blockers, especially clonidine may be used to help with withdrawal symptoms from opioids. It does not reduce the cravings but does help with the patient’s anxiety, agitation, and discomfort (muscle aches, cramping, diaphoresis, rhinorrhea).