NR 508 Week 4 Discussions 1

NR 508 Week 4 Discussions 1

NR 508 Week 4 Discussions 1

discussion part three

given cynthia’s increased creatinine and renal deterioration, metformin is probably not optimal in this case. therefore, upon subsequent visits, you decide to start her on a sulfonylurea. she reappears in your clinic fairly soon thereafter with complaints of shakiness, sweating, chills, clamminess, lightheadedness, and a moderately severe headache.

• what is the diagnosis given these symptoms and the medications she is currently taking from parts one and two, and how would you proceed? NR 508 Week 4 Discussions 1

• at this point, please also be sure to also provide an accurate summary of cynthia’s medication plan.

discussion part one 

cynthia is a 65-year-old african american female who presents to the clinic for a check-up. her last examination was ~5 years ago. she has no specific, significant, or urgent complaint. she explains that her only issues are thirst, fatigue, and leg numbness and tingling, which is beginning to occur more often. you decide to do a physical exam, as well as draw labs and receive the following results: NR 508 Week 4 Discussions 1

 social history: no smoking or alcohol consumption.

physical examination:

gen: well nourished, slightly obese female

vs: bp 180/103 hr 73 rr 13 t 98.4 weight 90 kg, height 5’6”

heent: perrla

cor: rrr, nmrg

chest: cta

neuro: monofilament test shows decreased peripheral sensation

ext: normal

laboratory (fasting):

na 139 meq/l

k 3.8 meq/l

alt 34 u/l

ca 9.1 mg/dl

cl 102 mmol/l

hco3 22 meq/l

ast 39 u/l

tp 6 g/dl

bun 33 mg/dl

scr 2.0 mg/dl

alb 4.1 g/dl

cholesterol 254 mg/dl

bg 300 mg/dl

tsh 0.12 mu/ml

ua: sg 1.013 mg/24h, ph 6.5, +++ protein

what are the major problems in this patient, and what diagnoses do these values indicate?

additionally, what is your assessment and pharmacological plan for each of these problems including the medication, dose, and mechanism of action? NR 508 Week 4 Discussions 1


The student will post one thread of at least 300 words For each thread, students must support their assertions with at least 1 scholarly citation in APA format (in text citations and references).  Any sources cited must have been published within the last five years unless it is deemed a seminal work in the field. Acceptable sources include textbooks, peer-reviewed journal articles, government websites, biblical sources (Bible, Bible dictionary, commentary, theological textbooks, etc).  NR 508 Week 4 Discussions 1

For this discussion, you practice conducting a Diagnostic Impression and writing up a Discussion of the Diagnostic Impression. Please attend to each step below.

1. Below in the Resources section, you will find 3 different case studies. You are to pick 1 case study (Thal, Juno, or Jesse). Read over the chosen case study. NR 508 Week 4 Discussions 1

2. In the first section of your initial thread, you will provide a principal DSM-5TR diagnosis as well as other diagnoses as appropriate based on your chosen case study. This could include a comorbid disorder and/or an appropriate Z-code. When offering a diagnosis put it in the format found in the Diagnosis Example of Penny found in the Resources section below (e.g., principal diagnosis formatted as, (ICD-10) disorder name, subtypes and/or specifier, severity, and/or course specifiers where applicable).

Then provide any co-morbidity disorders and/or Z-codes in the same format. You can also seek additional guidance in the Resources in the Additional Clarification for DSM-5 Diagnosis and What is a z-code below. There are also two sample diagnostic impression documents (e.g., Roberta and Peter) as well. You can review these resources to learn how to do a stepwise approach to arrive at a diagnosis. NR 508 Week 4 Discussions 1

2. In the next section of your initial thread, you will offer your Discussion of Diagnostic Impression. You can see how a Discussion of Diagnostic Impression is written in the Diagnosis Example of Penny below. The general formula is to provide the criteria met along with specific data points from the case study to support your appraisal (e.g. disorder criteria 1a plus case study data to support; then disorder criteria 1b plus case study data to support it). NR 508 Week 4 Discussions 1

It is also important to provide time frames (duration) for symptoms, e.g., The depressed mood duration is evidenced by the client reporting “feeling sad almost daily (A1) for the past 2 months. ; The client reported missing work because of a lack of energy (A6), etc”                                                                                                                                                                                                                                                                  The following resource has been obtained from the Diagnosis and Treatment Planning Skills: A Popular Culture Casebook Approach (DSM-5 Update) textbook. Permission for use in this way was granted in January 2022 by the publisher.

Toy Story’s Jessie

Introducing the Character

Jessie is one of the main characters in the Pixar/Disney animated blockbuster movie Toy Story 2 (Plotkin, Jackson, & Lasseter, 1999). In the story, Jessie is a cowgirl doll modeled after the fictitious cowgirl character in a 1960s children’s western TV show called Woody’s Roundup. The story centers on a band of toys who are going to be sold to a Japanese toy museum and their efforts to undermine that sale and remain together.NR 508 Week 4 Discussions 1

As the story unfolds, we learn that Jessie, once a favored toy to her owner, was abandoned when the girl grew out of her interest in childhood play things. Jessie was subsequently purchased by Al of Al’s Toy Barn, who was in the process of collecting a full set of toys that were marketed in conjunction with the Woody’s Roundup television show.NR 508 Week 4 Discussions 1

As Toy Story 2 unfolds, the pain of Jessie’s abandonment becomes obvious to the other toys, and especially to Woody, who is also struggling to remain in the favor of his boy owner, Andy. As the toys work together to overcome the differences that divide them, they ultimately rally to liberate themselves, and in the process, stage a last-minute rescue of Jessie and provide her once again with connection, attachment, and a sense of being loved. NR 508 Week 4 Discussions 1

Basic Case Summary

Identifying Information. Jessie, who refuses to use her last name because “it reminds me of them” (her foster parents), is an 11-year-old white preteen who has, for the last 3 months, been living at the Storyland Home for Girls. She has displayed increasingly disturbing asocial behavior at this facility, which has led to her spending increasing time alone, “shying away” from staff, and watching other peer residents with what was described as a “cold aloofness.” NR 508 Week 4 Discussions 1

In appearance, she can be described as a wiry, energetic, and wide-eyed red-haired waif. She has her own room at the facility because of her wary behavior and unwillingness to interact with the other residents. NR 508 Week 4 Discussions 1

Presenting Concerns. Jessie was referred for counseling by the disciplinary dean at the Storyland School due to escalating concerns about her highly ambivalent reactions to staff and peers.

Background, Family Information, and Relevant History. Jessie was born in Muskegon, Wisconsin, the youngest and unexpected third child to parents who were both under 20 years old. Jessie’s mother and father were both raised in the Wisconsin Foster Care System after being abandoned at birth; her father was in recovery for Alcohol Use Disorder. NR 508 Week 4 Discussions 1

When Jessie was born, her parents were living in a one-bedroom apartment over a grocery store in downtown Muskegon, were receiving government support, and had recently placed Jessie’s older brother up for adoption. NR 508 Week 4 Discussions 1

Jessie was born 5 weeks premature and presented a significant challenge to her young parents, who were referred to, but did not take advantage of, pre- and postnatal social services resources. As a result, Jessie

received poor postnatal care and was often left in the company of her parents’ friends, where she was also neglected. When Jessie was 1 year old, she was removed from her parents’ care and placed with a private foster family who hoped to adopt her; however, when those plans fell through, Jessie was move  into a foster-care facility where she remained until 4 years of age. NR 508 Week 4 Discussions 1

By that time, Jessie was already showing signs of disrupted attachment, including resisting the attentions of her foster parents, avoiding her foster parents’ soothing touch or comforting remarks, hiding from foster siblings in the home, and carefully watching babysitters before responding. She also began a habit of sometimes leaving the home and telling strangers that she was lost. NR 508 Week 4 Discussions 1

Invariably, she would be returned to the foster home. In spite of her troubled history, Jessie was once again adopted at age 6 by an ostensibly loving and older couple who convinced the state that they had ample financial and psychological resources to provide for the girl’s needs. However, Jessie was harassed by the biological child of this couple and when she began running away from their care at age 8 she had already displayed a

pattern of seeming to indiscriminately approach strangers on the sidewalk as if she was closely familiar to them.

When one of these “strangers” turned out to be a state care worker, Jessie was immediately removed from this couple’s care and placed with a middle-aged couple who had successfully raised their own children and who had been foster parents for 15 years. In that home, Jessie appeared to thrive and slowly began to trust her new parents. Although she tested limits, attempted to run away from home, aggressed toward them, and challenged their patience and experience, the couple’s commitment to the 9-year-old seemed to be having a positive effect on her. NR 508 Week 4 Discussions 1

By the time Jessie was enrolled in Storyland Middle School she, at least outwardly, appeared ready to enter into a new social world. She was placed in a small classroom with a teacher who had been extensively trained in providing for the educational and emotional needs of troubled children, and Jessie seemed to trust this woman, at least as much as she had ever trusted anyone before. She formed very tentative bonds with several classmates, mostly other troubled children, joined the school’s Martial Arts Program, and was referred to the school guidance department for possible inclusion in group and individual therapy.

Problem and Counseling History. Jessie was referred by the Storyland facility to Creative Counseling Consultants, where she was seen for three sessions separated by a week in time. She was a very charming and superficially endearing child who was playfully dressed in what appeared to be a cowgirl outfit and indicated that “this reminds me of that movie cartoon character who lost her parents and was looking for a family.” NR 508 Week 4 Discussions 1

Ironically, much of Jessie’s creative play, whether it was art, story-telling, clay modeling, or dollhouse activities, centered on themes of disrupted families, abuse of children, and retaliatory behavior against parents. Jessie’s affect during this disturbing play was quite flat as she recounted incidents in several of the foster and adoptive placements that “make me feel so angry and sad.” The results were a very highly destructive element to her play in that she would angrily erase, destroy, or negate her various creations, followed by a tantrum and withdrawal to a corner of the room. NR 508 Week 4 Discussions 1

She resisted supportive and compassionate gestures by the evaluator and made it quite clear that “I don’t like you and I’m only doing this because they made me.” At such moments, her body stiffened, her face reddened, and she quickly withdrew and stared off into space for minutes at a time. NR 508 Week 4 Discussions 1

Jessie spoke dispassionately about the various families with whom she had lived over the years and noted that “if they really loved me they would have kept me . . . I hate them all so much.” She angrily added that “they all thought that if they just sent me to a shrink, that I could be fixed . . . like some sort of broken toy.” NR 508 Week 4 Discussions 1

When asked about her current living situation, she quickly shot back with, “Oh yeah, they’re nice enough people, but I don’t think they’re going to keep me and maybe they’re just using me to get money from the state like everybody else.” NR 508 Week 4 Discussions 1

Nevertheless, Jessie acknowledged that they seemed different from previous foster or adoptive parents but that “I’m going to keep a really close eye on them and if they make one wrong move, that’s it.” Jessie denied having difficulty with her anger, trusting people, or feeling safe, but reluctantly agreed to return to counseling.