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Differential Dx - correct answer Diagnostic reasoning is the process of questioning one's thinking to determine if all possible avenues have been explored and if the conclusions that are drawn are based on evidence. This is a critical step for providers who are trying to uncover a cause, or diagnosis, for their clients' signs and symptoms. The provider's initial hypothesis is known as the differential diagnosis. The differential diagnosis, or differential, is a working list of potential problems that can be associated with the initial or chief complaint. Establishing a differential diagnosis is a critical step in providing safe, quality care. This evolving process of clinical reasoning and decision making involves examining the client's presentation, clinical data, and when appropriate, screening and diagnostic test results to distinguish one disease from another and arrive at the correct diagnosis. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR)provides guidance for identifying psychiatric diagnosest History of Present Illness - correct answer How long have you been feeling this way? Did something happen in your life that may have triggered these emotions? How is this current situation impacting your life?
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The Psychiatric History - correct answer Have you ever been hospitalized for any mental health issues? Have you ever had counseling or psychotherapy? Have you ever taken medications for your mental health in the past? Are you currently on any medications for mental health or sleep? Medical History/Screening for General Medical Conditions
- correct answer Do you have a primary care provider? Do you have any medical illnesses? Are you currently taking any medications or herbal supplements? Do you have any allergies to medications? Have you ever been hospitalized for any reason? Have you ever had surgery? Family Psychiatric History - correct answer Has any relative of yours ever been hospitalized for a mental health issue? Has any blood relative of yours ever been diagnosed with a mental health issue?
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Apply the Ask Suicide-Screening Questions (ASQ) Suicide Risk Screening Tool (Links to an external site.) to the scenario below. A 52-year-old client presents to the emergency department following a car accident. The emergency department (ED) physician is concerned that the client may have intentionally crashed her car and requests a stat PMHNP consult. In speaking with the PMHNP, the client describes persistent feelings of sadness and hopelessness. She states that she often wonders if her husband would be happier if she wasn't around anymore since she's never happy and sometimes thinks about what it would be like to just take a handful of sleeping pills and go to sleep forever. The client reports a previous suicide attempt when she was 16 but denies that she is considering killing herself right now. Based on the client's ASQ score, what is the most appropriate response? A) No action is necessary as the client is not - correct answer B)Provide a brief suicide safety assessment. Rationale: While the client's responses do not indicate a need for a stat full safety and mental health evaluation, the client requires a brief suicide safety assessment to determine whether a full mental health evaluation in
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necessary. It is also important to notify the client's physician or the clinician responsible for the client's care. Complete Blood Count - correct answer The CBC is a serum diagnostic test that measures red blood cells, white blood cells, hemoglobin, hematocrit, and platelets. The CBC includes a differential of the white blood cells. A CBC is often included as part of routine health screening or to obtain information related to specific conditions. In mental health, the CBC is used to rule out medical conditions that may present with symptoms that can be attributed to both medical and psychiatric diagnoses. For example, the CBC can help rule out anemia as a cause for depressive symptoms and fatigue or rule out infection as a cause of acute mental status changes. The CBC is also used to monitor certain treatment regimens. For example, some medications, such as clozapine, require routine analysis of absolute neutrophil count and platelet levels. Normal Range of: Red blood cells Hemoglobin Hematocrit
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Comprehensive Metabolic Panel (CMP) - correct answer The CMP is another common blood test used to determine general health status. The CMP includes several tests that provide information about fluid and electrolyte balance as well as the status of the body's metabolism, liver function, and kidney function. In psychiatric care, the CMP may be used to rule out medical conditions that could cause symptoms such as changes in mood or cognition. The CMP is also used to monitor the effects of medications, such as antipsychotics, on liver function and glucose levels. Normal CMP Levels Electrolytes Sodium (Na+): Postassium (K+): Chloride (Cl-): Bicarbonate (HCO3-): - correct answer Normal CMP Levels Electrolytes Sodium (Na+): 136-145 mEq/L Postassium (K+): 3.5-5.0 mEq/L Chloride (Cl-): 95-105 mEq/L
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Bicarbonate (HCO3-): 22-28 mEq/L Normal CMP levels Misc. Calcium, serum (Ca 2+) Glucose, serum Fasting: 2-h postprandial: Cholesterol, serum: Total Protein Albumin - correct answer Calcium, serum (Ca 2+) 8.4- 10.2 mg/dl Glucose, serum Fasting: 70-110 mg/dl; 2-h postprandial: <120mg/dl Cholesterol, serum: REC<200 mg/dl Total Protein 6.0-7.8 g/dl Albumin 3.5-5.5 g/dl Kidney Tests Creatinine, serum Urea nitrogen, serum (BUN) - correct answer Creatinine, serum 0.6-1.2mg/dl
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Vitamin B12 Level - correct answer Providers may choose to check vitamin B12 levels. Deficiency of vitamin B12 can affect mood and other brain functions. Common psychiatric symptoms associated with B12 deficiency include depression, mania, psychotic symptoms, and cognitive impairment ( A normal vitamin B12 level is between 190- picograms/mL. Between 200-300/mL indicates a borderline level with a possible need for additional testing. Vitamin D Level - correct answer Vitamin D affects functions such as neurotransmission, neuroprotection, and neuroimmunomodulation. Studies have indicated a high prevalence of vitamin D deficiency in clients with psychiatric disorders such as schizophrenia, depression, seasonal affective disorder, and cognitive impairment (Cuomo et al., 2019). Symptoms of vitamin D deficiency include depression, irritability, anxiety, psychosis, and poor brain development. A vitamin D level can be measured via the 25-hydroxy vitamin D blood test. A normal level is between 20- ng/mL. A level less than 12 ng/mL indicates a deficiency.
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Toxicology Screen - correct answer When diagnosing psychiatric conditions, providers may use toxicology screenings to rule out substance use as a cause for symptoms. Toxicology screenings are also used before starting therapy involving controlled substances, to monitor medication adherence, and in the diagnosis of substance use disorder. Urinalysis (UA) - correct answer Urinary tract infections are associated with a variety of neuropsychiatric symptoms (Lee et al., 2019). When clients present with acute mental status changes, a urinalysis may be used to rule out a urinary tract infection as the cause. Toni is a 58-year-old who presents with fatigue. Her TSH is 6.3 mIU/L. A) Begin Treatment B) Refer - correct answer B) Refer Rationale: A TSH level >4.0 is indicative of hypothyroidism, which is associated with fatigue. A referral for treatment of hypothyroidism is required. Client can be reevaluated for fatigue if symptoms persist after hypothyroid treatment has been initiated, TSH levels are within normal limits.
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Rationale: Vitamin D deficiency is associated with depressive symptoms. The PMHNP may refer or treat vitamin D deficiency depending on the level of comfort of the provider. Beth is a 24-year-old who presents with anxiety. Her T3 is 260 ng/dL. A) Begin Treatment B) Refer - correct answer B) Refer Rationale: Clients with hyperthyroidism have elevated T levels. Hyperthyroidism is associated with anxiety symptoms. Client can be reevaluated for anxiety once hyperthyroid treatment has been initiated and T3 levels are within normal limits. Fred is a 19-year-old who presents with psychosis. His vitamin B12 level is 900 picograms/mL. A) Begin Treatment B) Refer - correct answer A) Begin treatment Rationale: The B12 level is within normal limits. Treatment for symptoms of psychosis should be initiated. Ted is a 64-year-old who presents with confusion. His serum creatinine is 7.0 mg/dL and BUN is 32
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A) Begin Treatment B) Refer - correct answer B) Refer Rationale: Elevated serum creatinine and BUN indicate a problem with kidney function, which could contribute to confusion. Social Determinants of Health (SDOH) - correct answer 1: Discrimination, racism, social exclusion 2: Adverse early life experiences 3: Poor education 4: Unemployment, underemployment, job insecurity 5: Poverty 6: Neighborhood deprivation 7: Food insecurity 8: Poor housing quality and housing instability Holistic Care: Culture, Values, and Health Beliefs - correct answer Holistic approaches to mental health care consider all aspects of the individual, not just the symptoms and diagnosis. A holistic approach not only addresses psychiatric and medical considerations, it recognizes that social, spiritual, lifestyle, and behavioral elements also impact mental health. Psychiatric
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mental illness in the United States. Anxiety impacts approximately 18% of the adult population and 25% of children ages 13-17 each year (Anxiety & Depression Association of America [ADAA], n.d.). People who experience anxiety have a higher incidence of work and school absenteeism and higher use of medical resources, such as emergency department and provider visits than the general population First line of Tx for Generalized anxiety disorder? - correct answer SSRIs SNRIs Buspirone Drug Therapy at least 12 months First line of Tx for Panic Disorder? - correct answer Paroxetine Sertraline Fluoxetine Drug therapy 6-9 months First line of Tx for Obsessive compulsive disorder - correct answer Fluoxetine
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Fluvoxamine Sertraline Paroxetine Clomipramine (TCA) Drug therapy for at least 1 year First line of Tx for Social anxiety disorder - correct answer Sertraline Paroxetine Drug therapy takes 4 weeks to see effects First line of Tx for Post-traumatic stress disorder - correct answer Paroxetine Sertraline Hamilton Rating Scale HAM-A scoring Mild, moderate, severe - correct answer 0 (not present) 4 (severe) Total score ranges from 0- <17: indicated mild severity 18-24: mild to moderate severity
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Pt's with GAD show persistent, uncontrollable worrying that causes emotional distress and show symptoms on most days for a period of how long? - correct answer 6 months Pt's with anxiety often show increase activity in where? - correct answer Amygdala and prefrontal cortex Positron emission tomography (PET) scans show reduced what in pt's with anxiety? - correct answer Reduced serotonin binding What are risk factors for developing anxiety? - correct answer 1) family Hx
- being female
- recent life stressors
- chronic physical illness
- lack of support during childhood Increased brain activity in prefrontal cortex is a sign of? - correct answer Anxiety
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According to NIMH approximately _% of US adults will experience GAD in the past year and approximately ____ % of the US adults will experience GAD at some point in their lifetime **- correct answer** 3, 6 GAD is twice as common in ___________ than in __________
- correct answer Women, men How is GAD characterized by? - correct answer Persistent, uncontrollable worry about ordinary everyday situations Functional neuroimaging studies of GAD show? - correct answer Functional neuroimaging studies of GAD show increased activation of the amygdala and reduced activation in the prefrontal cortex, indicating heightened activation of the fear response with diminished capacity for reasoning GAD often presents with physical symptoms, including: - correct answer restlessness or edginess fatigue difficulty concentrating irritability
