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Clinical Case Presentation

Transcript: Technique Conclusion Patient Response 2010 Prominent leukoencephalopathy with multiple differential considerations as discussed above. 2006 MRI Following having a cavity filled, pt. experienced acute facial pain radiating down arm. Admitted to the hospital for 3 days. CAT scan. Discharged. Repeat MRI Again noted are multiple areas of increased T2 weighted signal throughout the hemispheric white matter which have progressed somewhat since the prior MRI of 2006. Some of these lesions are periventricular in location. There is no associated restricted diffusion and enhancement pattern is normal. A differential diagnosis exists. Possibilities would include small vessel scheming changes the patient has severe hypertension or diabetes. Another possibility would be demyelinating disease such as MS. No hemorrhage or mass lesions is present. Periventricular hyperintensities Diagnostic Criteria Impression Expanded Disability Status Scale Kurtzke, 1985 Impression Composed of 8 functional assessments: Visual Brainstem Pyramidal Cerebellar Sensory Bowel/Bladder Cerebral Other 2006 Dx: Multiple Sclerosis Relapsing/Remitting form Tx: Copaxone - daily Sub-Q injection Prognosis: Patient is maintaining functional status. EDSS = 3.5 She has had one exacerbation since starting DMD. Adherence to tx regime difficult due to pt's thinness. Considering switching to Tysabri (monoclonal antibody given once-a-month by IV infusion) Referral to Neurologist for workup following an acute loss of vision in both OS/OD, increased fatigue, weakness and headache. MRI: The examination is abnormal and reveals prominent rather symmetric regions of leukoencephalopathy in the deep white matter tracts, primarily in the subcortical portions of the centrum semiovale and adjacent to the lateral ventricular surfaces. A few of these regions are associated with diffusion restriction; no abnormal enhancement or mass effect is seen. These changes are suspicious for either prominent demyelinating disease such as multiple sclerosis or perhaps exuberant chronic microvascular disease for age. Other considerations such as vasculitis would seem reasonable as well. 2010 MRI Extensive signal abnormality within the white matter which has progressed since previous studies White Matter Hyperintensities "Please call pt. MRI brain & orbits was essentially the same as in 2006." Patient: M.S. Age: 59 Gender: Female Race/ethnicity: White, non-Hispanic Chief Complaint: 20+ year history of temporary bilateral vision loss, headache/migraine, eye pain, balance impairment, vertigo, peripherial neuropathy (feet), weakness, and fatigue. Clinical Case Presentation Janet Morrison RN, MSN, MSCN Clinical Case Presentation of Multiple Sclerosis At 1.5 Tesla, appropriate pulse sequences were employed in multiple planes both before and after the IV administration of a gadolinium contrast agent. 1983 - Age 30 Abrupt onset bilateral vision loss lasting 10 days. H/O spousal abuse. Diagnosis: Atypical Migraine Ongoing symptoms - retrobulbar pain when looking up or down, Intermittent vision & balance problems, Peripheral neuropathy (feet). Hospitalized 5+ times. Dx: Viral Labyrinthitis. Tx: Ativan, Compazine. 1993 - Age 40 Neurologist consulted. EEG. Electromyelogram. Dx: Migraine & Vertigo. Tx: Depakote 1995 - Age 42 MVA Concussion, Seat belt trauma. 2006 - Age 53 Fell down stairs due to weakness. Fractured 3 thoracic vertebral bodies and coccyx. Relevant Past History Patient called radiology group requesting her MRIs from 2006 and 2010. Read radiologist's reports. Sought opinion from another neurologist. Diagnosis: Multiple Sclerosis Self-referred to university-based MS Neurology Clinic in a large urban health science center. Workup included repeat MRI, opthalmological exam, spinal tap, evoked potentials. Dx: Confirmed MS Tx: Copaxone Expanded Disability Status Scale EDSS "Tell pt. it showed some white spots which is common in migraines" Spoke with pt. 8/16/06

Clinical Case Presentation

Transcript: Funding Cognitive/Perceptual (Carpenito-Moyet, 2010) i. Knowledge deficit related to new condition as evidenced by verbalizing having “a new heart”, being “good as new”, and wanting to resume normal ADLs Health Perception/Management Nutrition/Metabolic Health Perception/Management i. “New heart” ii. Feels able to return to normal and more iii. Does not feel tired with exertion but vitals increase significantly Nutrition/Metabolic i. “Whole ingredients” ii. Bacon iii. Temporary versus permanent diet change Cognitive/Perceptual i. Did not finish college ii. New self iii. Surgeon: “Good as new” Procedure Physical Assessment/Charting by Exception Strong heartbeat, not +4 bounding pulse 18 cm sternal wound, approximated, scabbing, no significant erythema/exudate 1-2.5 cm wounds approximated, scabbing, no significant erythema/exudate Medial aspect of right leg Medial aspect of right popliteal Medial aspect of right inguinal Medicare Railroad United Health Care a. The patient will verbalize 2 reasons why he is on restricted activity by the end of the home visit. i. The objective will be met when the patient verbalizes 2 reasons why he is on restricted activity by the end of the home visit. b. The patient will verbalize 2 reasons why he is on a cardiac diet by the end of the home visit (next week). i. The objective will be met when the patient verbalizes verbalize 2 reasons why he is on a cardiac diet by the end of the home visit (next week). c. The patient will collaborate with the health care team and his wife to create a favorite dish that is appropriate with his cardiac diet by the end of the month. i. The objective will be met when the patient successfully prepares a favorite dish with his wife that is appropriate with his cardiac diet by the end of the month. Plan Carpenito-Moyet, L. (2010). Nursing diagnosis: Application to clinical practice (12th ed.). Philadelphia, PA: Lippincott, Williams, & Williams. National Public Radio. 2013. Behind the ever-expanding American dream home. Retrieved from http://www.npr.org/templates/story/story.php?storyId=5525283 Photos Best Clip Art Blog. (2005). Heart health. Retrieved from http://bestclipartblog.com/clipart-pics/health-clip-art-2.gif Can Stock Photo. (2011). Thumbs team. Retrieved from http://ec.l.thumbs.canstockphoto.com/canstock6304481.jpg Clip Art Heaven. (2013). Real estate house. Retrieved from http://www.clipartheaven.com/clipart/real_estate/house_38.gif Clip Art Stock Photo. (2012). Image 2423. Retrieved from http://clipartstockphoto.com/images/doctor-clip-art.jpg Family and Friends. (2013). Clip arts. Retrieved from http://familyandfriends.phillipmartin.info/grandparents.gif PBTPNG. (2010). The doctor is in. Retrieved from http://www.pbtpng.org/the-doctor-is-in QACPS. (2012). Carlson clip art. Retrieved from http://www.qacps.k12.md.us/ces/clipart/Carson%20Dellosa%20Clipart/Carson%20Dellosa%20Learning%20Themes/Images/Color%20Images/Community%20Helpers/BLOOD_PRESSURE_CUFF.jpg Wordpress. (2011). Clip art 0002. Retrieved from http://maryanncp.files.wordpress.com/2009/06/clip-art0020.jpg Word Fitness (2013). Heart rate monitor. Retrieved from http://www.mumsthewordfitness.com.au/wp-content/uploads/2012/02/heart_rate_monitor.gif Clinical Case Presentation NUR 412 Home Health Nursing Jamie Mones Objectives and Planned Evaluation Durable Medical Equipment Resources Interdisciplinary Team i. Cardio-surgeon ii. Home Health Nurse iii. Physical Therapy iv. Occupational Therapy Teaching Required for the Patient/ Family i. See Gentiva Cardiac Journal ii. Documentation 1. Vitals 2. Diet 3. Activity iii. Diet iv. Activity v. Post-Operative 1. Normal/abnormal incision 2. Sleeping position 3. Breathing/brace/spirometer Procedure Bacon Lifestyle alterations Sphygmomanomenter Open Heart Quintuple Bypass Surgery Gentiva Sun City West D.L. 53 years old Hispanic Male 1 week S/P open heart quintuple bypass surgery (9/19/13) Used right great saphenous vein Main diagnosis: stroke Culture, Ethics, and Spirituality Introduction Family 1. Wife 2. Sister 3. No children Culture 1. Hispanic 2. Traditional cooking 3. “Whole” ingredients 4. Gender role: patriarchal Culture i. Diet ii. Gender roles Ethics i. Autonomy ii. Beneficence v nonmaleficence 1. Patient’s outcome versus frustration/depression/stress 2. Catch-22 Skills/Physical Interventions Ordered i. Cardio-pulmonary (with peripheral pulses) ii. Wounds iii. Monitored activity (PT) iv. Breathing exercises (PT/OT) v. Energy conservation (OT) Complementary Therapies i. None ii. Culture-specific support group Summary Environmental factors 1. Sun City West 2. Property 2,500-3,000 sq ft +/- outside amenities 3. Average, borderline high average size (NPR, 2013) 4. No pets Resources and Referral Environment Banner Boswell Medical Center, Sun City Banner Del E. Webb Medical Center, Sun City West Homewatch Caregivers, Sun City Priority Nursing Diagnoses Significant Functional Health Patterns (FHPs)

Psychology Clinical Case Presentation

Transcript: Psychology Clinical Case Presentation An In-Depth Analysis of Client Treatment and Outcomes Mental State Exam Presenting Problem and History The mental state exam revealed significant findings, including elevated anxiety levels, mood fluctuations, and cognitive distortions. Notable features included impaired insight and fluctuating affect, which indicated underlying psychological distress. Understanding the presenting problems in a clinical context is crucial for effective diagnosis and treatment plans. Each client's history and state at presentation provide significant insights into their psychological conditions. Referral Source and Reason Service Delivered The treatment was delivered at a community mental health clinic specializing in anxiety and mood disorders. Services included individual therapy sessions focused on cognitive-behavioral therapy (CBT), which aimed to equip the client with coping strategies and skills to manage symptoms effectively. Treatment History The client was referred to therapy by her primary care physician due to persistent anxiety and depressive symptoms. The physician highlighted concerns regarding the client's ability to manage daily responsibilities at work and home, prompting the need for psychological intervention. Key Features of Presentation Demographic Details The client has undergone several treatment plans, including cognitive-behavioral therapy and medication management. While some approaches yielded temporary relief, the lack of consistent adherence to treatment plans hindered sustained progress. Key features of the presentation include persistent avoidance behavior and negative self-image. The client also demonstrated heightened emotional reactivity, impacting social interactions and daily functioning. The client is a 28-year-old female, living with her partner and two children. Educationally, she holds a bachelor’s degree in psychology and has been employed as a high school teacher for five years. Family dynamics are supportive yet strained due to work-related stressors. Client Details Changes Over Time Current Topography and Impact This section provides a comprehensive overview of the client’s background, including key demographic data, referral reasons, specifics of the service delivered, and the number of sessions conducted. Understanding these elements is crucial for contextualizing the therapeutic journey and outcomes. Number of Sessions The current topography of symptoms includes intrusive thoughts and difficulty managing emotions. The impact is significant, leading to impaired relationships and occupational challenges due to heightened anxiety and depressive symptoms. Over time, the client's symptoms have oscillated between mild to severe, with increased episodes of panic associated with stressors in life. Historical treatment engagements indicated some responsiveness to earlier interventions, yet relapses occurred without sustained support. The client participated in a total of 12 therapy sessions over a period of three months. Each session lasted approximately 60 minutes, allowing for consistent progress tracking and adjustments to the treatment plan based on the client’s evolving needs. Health and Medical Status A comprehensive understanding of the client’s health history is vital. Past medical issues, including chronic illnesses and developmental milestones, significantly influence psychological outcomes, especially in children and adolescents. School Environment Community and Cultural Connection Connection to community and cultural identity can enhance coping mechanisms and provide support systems. Cultural practices and community ties deeply influence the client’s perspectives on mental health and treatment acceptance. The school environment shapes academic performance and social skills. Challenges such as academic pressure, teacher relationships, and school climate can contribute to mental health issues, making education a critical area for intervention. Diagnostic Issues Peer Relationships Peer interactions are essential for social development and emotional support. The quality of friendships and the presence of conflict or bullying can significantly affect the client's self-image and mental state, exacerbating existing issues or contributing to new ones. Psychosocial Background Applicable Diagnostic Categories Understanding a client's psychosocial background is crucial for effective treatment planning and prognosis. This section examines various societal and familial factors that significantly impact the client's mental health. Formulation: Understanding Client Challenges Understanding diagnostic issues is crucial for proper case formulation and treatment planning. Accurate diagnosis can significantly influence therapeutic outcomes and client engagement. Several diagnostic categories may apply to the case, such as Major Depressive Disorder, Generalized Anxiety Disorder, or Adjustment Disorders. Identifying the correct diagnosis is essential for

Clinical Case Presentation

Transcript: Priority Nursing Diagnosis Taylor Laboratory Values ARB Fetopathy Nursing Diagnosis Gain weight get to 10kg to get on kidney transplant list! Strengthen muscles to reach developmental milestones Songs of Love Foundation Detroit Specialty Center -> Outpatient Therapy Complications were more severe and more frequently noted in children prenatally exposed to ARBs throughout the entire pregnancy. Women of childbearing age should be educated on the effects of these drugs during pregnancy and they should only be used if absolutely necessary. Quality of life patient will have to continue dialysis until she can get a kidney transplant QOL will be greater with a transplant Affect her growth and development Palliative care Beneficence -> to do good Non-maleficence -> to do no harm Truthfulness -> be truthful about the pts condition and treatments Autonomy -> respect the grandparents wishes Legal Guardianship -> grandparents Midnight Temp: 36.9 HR: 153 Resp: 32 BP: 112/61 O2: 99% Spiritual & Cultural QUESTIONS? Vaccines -> Rates of vaccination against influenza in the pediatric ESRD population have improved, but remain below recommended levels (Carson, 2012). Clinical Case Presentation Risk for electrolyte imbalance r/t end stage renal disease. Patient Assessment Medications Plan of Care Outcomes: 1.) By the end of the shift, pt will remain free from s/s of infection 2.) By discharge, caregivers will be able to identify s/s of infection and demonstrate how to take the pt's temperature Interventions: Assess temperature and observe skin for redness & warmth Hand hygiene Cluster nursing care to decrease number of contacts with pt Educate caregivers on the importance of hand hygiene in preventing infections Educate caregivers how to monitor the pt's temperature Encourage vaccinations Evaluation: 1.) Outcome met -> pt remained afebrile and free from s/s of infection throughout the shift. 2.) Outcome met -> Caregivers verbalized s/s of infection and exhibited how to monitor the pt's temperature Economic & Social Factors Delayed growth and development r/t effects of chronic disease (ESRD) & long periods of hospitalizations since birth AEB difficulty in performing skills typical of age group and altered physical growth. Anemia in Chronic Kidney Disease (2014). In National Institute of Diabetes and Digestive and Kidney Disease. Retrieved March 19, 2016, from http://www.niddk.nih.gov/health-information/health-topics/kidney-disease/anemia-in-kidney-disease-and-dialysis/Pages/facts.aspx. Bullo, M., Tschumi, S., Bucher, B., Bianchetti, M., & Simonetti, G. (2012). Pregnancy outcome following exposure to angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists: A systematic review. Hypertension, 60, 444-450 Carson, R. (2015). 2015 USRDS annual data report. In United States Renal Data System. Retrieved March 19, 2016, from http://www.usrds.org/2015/view/v2_08.aspx. Cho, M. (2013). Clinical approach to quality of life in children with end-stage renal disease. Korean Journal of Pediatrics, 56(8), 323-326 End stage renal disease (ESRD) in the pediatric patient (2015). In Carolinas HealthCare System. Retrieved March 20, 2016, from http://www.carolinashealthcare.org/documents/ACEModules/ACE_ERSDPediatricPatient_FINAL.pdf. Hyperparathyroidism (2016). In Mayo Clinic. Retrieved March 20, 2016, from http://www.mayoclinic.org/diseases-conditions/hyperparathyroidism. Plazanet, C., Arrondel, C., Chavant, F., & Gubler, M. (2014). Fetal renin-angiotensin-system blockade syndrome: Renal lesions. Pediatric Nephrology, 29, 1221-1230. Richards, C. (2016). Pediatric renal transplantation. Nephrology Nursing Journal, 43(1), 35-37. 8:00 p.m. Temp: 36.4 HR: 159 Resp: 42 BP: 120/70 O2: 96% Social Work Nephrology Nutrition PT/OT Medicare Smoking -> Grandfather smokes outside the house Mom Dad is not in the picture No siblings Grandparents are the legal guardians Referrals & Community Resources Diagnostic Tests M.W. has hemodialysis M, W, F & some Saturdays No wet diapers, but regular BM On room air She has a G/J Tube placed G tube to dependent drainage J tube is for medications & feedings of special pm 60/40 formula at 44 mL/hr She is on continuous pulse ox and CR monitoring, as well as strict I&O's Risk for infection r/t chronic disease, presence of central venous catheters, & hemodialysis. CBC: WBC 24.8 ( ) RBC 2.63 ( ) Hgb 7.2 ( ) Hct 24.0 ( ) Platelets 228 Na, K, and Phosphorous are within normal limits. Ca level increase could be attributed to her hyperparathyroidism (too much PTH secondary to the kidney failure). The kidneys are damaged, so they are not making enough Erythropoietin, which stimulates the bone marrow to make red blood cells. As a result, the bone marrow makes fewer red blood cells, causing anemia -> This is why the patient is receiving Epoetin alfa. BUN and Creatinine are normally removed by the kidneys, but since the kidneys are not functioning, these levels in the blood increase. References Community of Residence

Clinical Psychology Presentation

Transcript: Career choice: Clinical Psychologist Job description Diagnose and treat mental disorders; learning disabilities; and cognitive, behavioral, and emotional problems using individual, child, family, and group therapies, and implement behavior modification programs” (http://www.careerinfonet.org). “They foster well-being by promoting good mental health and preventing mental, physical, and social disorders. They work in settings such as universities or crisis counseling centers, hospitals, rehabilitation centers, and individual or group practices” (http://www.bls.gov). Type of Patients personal and family relationship problems depression and schizophrenia eating disorders addictive behaviors neurological disorders Skills needed Speaking — Talking to others to convey information effectively. Critical Thinking — Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems. Reading Comprehension — Understanding written work related documents. Writing — Communicating effectively in writing as appropriate for the needs of the audience. Active Listening — Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times. Social Perceptiveness — Being aware of others' reactions and understanding why they react as they do. Active Learning — Understanding the implications of new information for both current and future problem-solving and decision-making. Complex Problem Solving — Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions. Science — Using scientific rules and methods to solve problems Education The Chicago School of Professional Psychology of Los Angeles University of California of San Diego Contiguous B.S./M.A. Degree Program Many jobs require a Ph.D. and a state license Loma Linda University Loma Linda University Psychology Program Percentage of program graduates who have become licensed psychologists 92% For six years it is about $165,631.00 Money Median wages (2009) $31.75 hourly $66,040 annual Projected growth (2008-2018) Average (7% to 13%) Projected job openings (2008-2018) 59,900 What 3 Holland Codes Do Clinical Psychologist Fall Under? ISA Investigative - working with ideas, and require an extensive amount of thinking. These occupations can involve searching for facts and figuring out problems mentally. Artistic -They often require self-expression, and the work can be done without following a clear set of rules. over 40% of psychologists are self-employed. The reason psychologists become self-employed is because they have more leeway of what they want to do Social - involve working with, communicating, and teaching people. These occupations involve helping or providing service to others. The job titles of people clinical psychologists work with are: Counselors Recreational workers Human resources Sociologist Political scientist Social workers Informational Interview Gene "Gin" Ano, Ph.D. Professor, Department of Psychology Mount San Antonio College What is your job like? Very rewarding to be a part of people's journeys toward healing and growth. Can you suggest some ways a student could obtain this necessary experience? Study and work hard and develop professional networks in order to learn the necessary skills and get into and succeed in graduate school. Do you have any special words of warning or encouragement as a result of your experience? Try to make sure it is what you want to do because the preparation and training can be intense. Also, because people are depending on you with intimate details of their lives, you want to make sure you are invested in the purpose of what you are doing. What kinds of problems do your patiens have? Mostly depression, anxiety, and relationship issues. Thank You (http://www.onetonline.org).

Clinical Case Presentation

Transcript: David not only experienced a sudden loss but also a significant rupture in the family system. Brief Strategic Family Therapy Psychiatric Social Worker Conduct intakes with the youth and family Complete psychosocial assessments Facilitate social work psycho-educational and psychotherapy groups Assess the appropriate level of follow-up care to effectively coordinate discharge plans Brief, pragmatic, behavioral process rather than content Define and resolve the problem Establish clear, achievable, and measurable goals Initial Session is key component to therapy Brief Therapy Stage Problem Stage Interactional Stage Goal-Setting Stage Task-Setting Stage 2. Family Therapy Triage: What to address first? Structual/ Strategic Family Therapy Theory Behaviors reflect maladaptive family interactions Every behavior is a form of communication - no such thing as no communication Family rules - not what's supposed to be but what is References Modeled after the following values Connectedness vs. Individual Autonomy Present vs. Past Theory BSFT Model Short-term (~12 sessions) Youth with behavioral problems Decreases youth problems, improves functioning in families MRI Model David P. Bitter, J. R. (2014). Theory and practice of family therapy and counseling (2nd ed.). Belmont, CA: Brooks/ Cole/ Cengage. Nichols, M.P. (2009). Inside family therapy: a case study in family healing (2nd ed). Boston, MA: Allyn & Bacon. ISBN 978-0-205-61107-2 Szapocznik, J., Schwartz, S. J., Muir, J. A., & Brown, C. H. (2012). Brief strategic family therapy: An intervention to reduce adolescent risk behavior.Couple and Family Psychology: Research and Practice, 1(2), 134 Walter, C. A., McCoyd, J. L., & Walter, P. C. A. (2015). Grief and loss across the lifespan: A biopsychosocial perspective. Springer Publishing Company. 11 y/o male admitted due to suicide attempt via attempting to hang self As per youth, admitted due to becoming aggressive at home with primary guardian Aunt J. Admitted for 13 days (average length of stay ~ 6) Adjustment disorder with disturbance of conduct As per family, youth was admitted due to out of control, defiant, and oppositional behaviors School refusal Lack of communication Manipulation Destructive and aggressive outbursts Aunt J. Tracking & Diagnostic Enactment Discussion 1. The "Opening the Wound" Dilemma Maternal Aunt is primary guardian Adult sister resides in Atlanta, GA Mother passed away from cancer (5 y/o) Father incarcerated (6 y/o) Monmouth Medical Center CCIS Treatment and stabilization for those in crisis, ages 5-17 Primary treatment goal is to stabilize the acute phase and identify the emotional and behavioral needs of the youth BSFT 3 Core Principles 2. Habitual/ repetitive patterns influence behaviors of each family member 3. Should interventions be modified when working with families such as David's? If so, how? BSFT 4 Intervention Domains Agency Background Focuses on diagnosing family interactional patterns and restructuring the family interactions associated with the adolescent behaviors "David P." Clinical Case Presentation Melissa Genovese CSW II February 25, 2016 3. Interventions are problem-focused and targeted Family Context 1. Family-systems approach Joining Reframing Restructuring

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