NRNP 6541F – Primary Care of Adolescents and Children

NRNP 6541F – Primary Care of Adolescents and Children

Patient Information: E. H, 16, Female.

Subjective:

CC: Weight loss.

HPI: E. H is a 16-year-old female who presents to the center with her mother, claiming to have lost 20 pounds in the last six months. According to her mother, the patient has been purposefully restricting her food intake and exercising excessively to combat her feelings of being overweight. Additionally, the patient reports having episodes of binge eating and self-induced vomiting approximately twice a week. Additionally, she states that she has been feeling tired for the majority of the day and is not as energized as she once was. She also claims to have fainted once last week after a volleyball game. Additionally, she reports a lack of interest in several of her activities and sadness sometimes.  Additionally, she reports using laxatives on occasion for constipation. She also reports amenorrhea and sleep deprivation. According to her mother, the patient is occasionally anxious and concerned about how others will perceive or judge her, but she continues to excel at everything. The patient states that she is in good health and wishes to continue losing weight. Her mother claims that she is unable to determine whether anything her weight loss problem better or worse. According to her mother, she has not yet received any treatment for her weight loss. The patient denies pain.

Current Medications: OTC Laxatives.

Allergies: No known allergies were reported.

Pertinent PMHx: According to her mother, she’s always been a healthy, cheerful girl up until now. The immunizations are up to date for his age. The patient denies hospitalizations. She had a metatarsal stress fracture three months ago.

Developmental: Until now, the patient has grown normally without encountering any health complications. She is in the eleventh grade and has an excellent academic record. She is cognitively mature for her age. She reports social anxiety and phobias associated with her weight perceptions. She states that she sleeps well, but if she hasn’t exercised enough during the day, she wakes up in the middle of the night and does some sit-ups before falling back to sleep. She typically sleeps four to five hours per day. She also experiences times of sadness. Additionally, she states that she is uninterested in dating. She enjoys volleyball and also works out at a gym.

Soc Hx: Her parents divorced last year; however, during the week, her sister and she spend time with both of them. Currently, she is enrolled in a high school. Additionally, she denies ever having used tobacco, alcohol, or any other substance. Additionally, the patient does not engage in sexual activity. She enjoys playing volleyball.

Fam Hx: According to her mother, the whole family is healthy.

ROS:

GENERAL: The patient denies fevers, chills, or night sweats. She reports weight loss, tiredness, and sleep deprivation.

HEENT: Eyes: The patient reports no visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: She denies hearing loss, congestion, runny nose, sore throat, or difficulty swallowing.

SKIN: The patient denies rash or itching.

CARDIOVASCULAR: The patient denies chest pain, pressure, palpitations, or discomfort.

RESPIRATORY: The patient denies shortness of breath, cough, or sputum production.

GASTROINTESTINAL: The patient denies changes in appetite, bloating, heartburn, burping, coffee ground emesis, black, tarry stools, diarrhoea, or food intolerance. She admits to self-induced vomiting, binge eating, and constipation.

GENITOURINARY: The patient denies burning on urination, past UTI, and blood in the urine. She admits that her last menstrual period was three months ago.

NEUROLOGICAL: The patient denies headache, dizziness, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. She admits to fainting and experiencing syncope once last week.

MUSCULOSKELETAL: No muscle or back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: Reports no atypical swollen lymph nodes.

PSYCHIATRIC: She reports social anxiety and phobias associated with her weight perceptions. She also admits to a lack of interest, sadness, and anxiety.

ENDOCRINOLOGIC: No history of endocrine disorder. No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

ALLERGIES: No known allergies.

Objective:

Vital Signs: HR: 68/minute, RR: 14/minute, B/P: 90/60 mm Hg, TEMP: 95.9, SPO2: 99% Weight 100 Lbs, Height 5’7”, Height Percentile: 86.4, BMI 15.7 kg/m2

Physical exam:

General: The patient is AAO x4 and well-groomed. However, she appears cachexic, slightly anxious, and tired. She has an appropriate speech and ambulates normally.

Skin, Hair, Nails: The skin is warm, rough, and dry. She has abrasions and calluses on the dorsa of the right hand. Her hair is thin, and she has a dry scalp. She has lanugo body hair. She also has brittle, chewed nails.

HEENT: Head: Normocephalic. Eyes: Pupils are equal round, equal, and sensitive to light.

Ears:  The patient has normal-appearing external structures without deformities or edema. No discharge was noted. Nose and Throat: No sneezing, running nose, congestion, or sore throat. She has cracked lips, angular stomatitis, and yellow-colored teeth with visible caries. Neck: She has bilateral parotid enlargement. The thyroid size consistency is WNL. No cervical lymphadenopathy noted. There is no increase in jugular venous pressure.

Cardiovascular: S1 and S2 were heard on auscultation; no rubs, gallops, or murmurs were noted. PMI is nondisplaced.

Respiratory: Lungs sound clear per auscultation; no coughing was observed during the visit. Chest rise is symmetrical, with no accessory muscle use.

Gastrointestinal: The abdomen is lean and non-distended. The patient does not appear to have a herniation. Palpation of the abdomen reveals it to be soft and non-tender. There is no organomegaly, abdominal mass, or inguinal mass present. In all four quadrants, bowel sounds are present and normoactive. The abdomen is normal to percussion. No tympanic or shifting dullness note.

Genitourinary: Deferred

Musculoskeletal: The test strength is normal. No tenderness, muscular resistance, rigidity, asymmetry, or deformity was noted. ROM is equal bilaterally on the upper and lower extremities.

Neurological: Cranial nerves II-XII appear grossly intact. No overt sensory/motor deficits are appreciated. The cerebellar function is grossly intact. She has reduced muscle bulk for age and height. Sensation is intact for fine touch, crude touch, pain, temperature, vibration, and position sense.

Psychological: Deferred

Lymphatic: No regional lymphadenopathy.

Hematologic: Deferred

Rectal: Deferred.

Diagnostic results:

Assessment:

Primary diagnosis:

Anorexia Nervosa: Binge Eating/Purging (F50.02): This condition is accompanied by episodes of binge eating or purging behaviour where one self-induces vomiting or misuses laxatives (Gibson et al., 2019). The patient has been purposefully limiting her food intake and excessively exercising to combat any feelings of being overweight. The patient also reports instances of binge eating followed by episodes of self-induced vomiting. There is also a report on the use of laxatives. All these presenting complaints support a diagnosis of anorexia nervosa, binge eating, and purging.

Differential diagnosis:

Anorexia: Restricting type (F50.01): Anorexia nervosa restricting type is a subtype of anorexia nervosa where one greatly restricts food intake and focuses on losing weight through excessive exercise, fasting, or dieting. Binge eating episodes, as well as purging episodes, are not common in this condition. The restricting type of anorexia nervosa presents with reduced food intake and great effort and focus on weight loss. Binge eating and purging episodes are, however, not often observed (Lindvall Dahlgren et al., 2017). The instances of binge eating and purging observed twice a week, therefore, rule out this diagnosis

Bulimia Nervosa (F50.2): Bulimia nervosa is an eating disorder characterized by episodes of binge eating followed by episodes of purging (Galmiche et al., 2019). The instances of restricting food intake rule out bulimia nervosa, which is characterized by episodes of binge eating followed by the application of unhealthy ways such as purging to get rid of the excess calories.

Major Depressive Disorder (F32.9): Major depressive disorder is a mood disorder characterized by constant low mood and loss of interest in previously pleasurable activities. It greatly affects the way an individual thinks, feels, and behaves (Hasin et al., 2018). The patient complains of episodes where she feels sad sometimes, loss of interest in previously pleasurable activities, and a feeling of diminished energy levels for the majority of the day. The additional eating disorders, however, rule out this condition as they indicate that the diagnosis is most likely an eating disorder.

 Plan:

Diagnostic Tests: A Complete Blood Count (CBC) is important for checking for the presence of anaemia or any infection that may be causing the symptoms being observed. A Comprehensive Metabolic Profile (CMP) assessing blood glucose, electrolytes, bicarbonate levels, creatinine and creatinine clearance, liver enzymes, blood urea nitrogen, and total bilirubin is also critical in making a comprehensive diagnosis (Avila et al., 2019). A urinalysis can be performed to assess the presence of ketones and the urine-specific gravity, which is critical in determining dehydration and fluid intake.

Consults: A multidisciplinary team is critical in aiding individuals in overcoming eating disorders. A paediatrician is a critical member of this team. He or she is trained and well-equipped to deal with infants, children, and adolescents. Pediatricians greatly assist children and adolescents with eating disorders by talking to both the child and caregiver and recommending treatment or referral to another specialist (McMaster et al., 2020). Psychologists are key as they provide counselling and education aimed at dealing with eating disorders. Dieticians and nutritionists offer expert advice on both diet and nutrition and offer education regarding eating disorders. This is pivotal in dealing with this issue. Occupational and rehabilitation therapists are also key players. They assist individuals with eating disorders in the development and implementation of life skills that are critical in dealing with eating disorders. When writing the admission note, I would highlight the severity of the condition to ensure direct admission.

Therapeutic modalities: In the instance of anorexia nervosa, there is no specific medication approved to treat this condition. Antidepressants may be indicated to deal with other psychiatric conditions that may accompany anorexia nervosa, such as depression. In this case scenario, an initial 10 milligrams of Prozac should be administered (Sadowsky, 2021). This can be increased to 20 milligrams each day. This should be continued for a duration of around eight to nine weeks to fully address the depressive symptoms. Psychotherapy is also critical in the management of the condition. This can be done as family-based therapy or individual therapy.

Health Promotion: Health promotion involves familiarizing oneself with the condition through education, talking to people who are at greater risk of developing the condition, and offering them support. Seeking medical assistance and building a strong support network is also vital in reducing the risk of developing anorexia nervosa.

Patient education: It is important to educate patients on the importance of a healthy diet and proper nutrition. Highlighting the importance of a meal plan is also critical. It is also important to educate the patient about self-awareness and acceptance (Bullivant et al., 2019}. This is critical in combating anorexia nervosa. Encouraging the patient to engage in other social activities greatly boosts her confidence and minimizes the risk of developing the condition. It is also vital to educate family members and other care providers on the symptoms to look out for and the importance of seeking medical help the minute they observe these symptoms and signs.

Follow-up instructions: Follow-up instructions include the need to maintain appropriate weight through adequate dietary intake, elimination of binge and purging practices. The importance of addressing esteem issues and developing long-term behavioral goals should also be insisted on (Gan et al., 2021). The patient should be encouraged to seek medical help if the condition reoccurs. Referral to a specialist should also be considered in instances where signs and symptoms persist or become severe.

References.

Avila, J. T., Park, K. T., & Golden, N. H. (2019). Eating disorders in adolescents with chronic gastrointestinal and endocrine diseases. The Lancet. Child & adolescent health, 3(3), 181–189. https://doi.org/10.1016/S2352-4642(18)30386-9

Bullivant, B., Denham, A. R., Stephens, C., Olson, R. E., Mitchison, D., Gill, T., Maguire, S., Latner, J. D., Hay, P., Rodgers, B., Stevenson, R. J., Touyz, S., & Mond, J. M. (2019). Elucidating knowledge and beliefs about obesity and eating disorders among key stakeholders: paving the way for an integrated approach to health promotion. BMC Public Health, 19(1), 1681. https://doi.org/10.1186/s12889-019-7971-y

Galmiche, M., Déchelotte, P., Lambert, G., & Tavolacci, M. P. (2019). Prevalence of eating disorders over the 2000-2018 period: a systematic literature review. The American journal of clinical nutrition, 109(5), 1402–1413. https://doi.org/10.1093/ajcn/nqy342

Gan, J., Wu, V. X., Chow, G., Chan, J., & Klainin-Yobas, P. (2021). Effectiveness of non-pharmacological interventions on individuals with anorexia nervosa: A systematic review and meta-analysis. Patient education and counselling, S0738-3991(21)00386-4. Advanced online publication. https://doi.org/10.1016/j.pec.2021.05.031

Gibson, D., Workman, C., & Mehler, P. S. (2019). Medical Complications of Anorexia Nervosa and Bulimia Nervosa. The Psychiatric Clinics of North America, 42(2), 263–274. https://doi.org/10.1016/j.psc.2019.01.009

Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018). Epidemiology of Adult DSM-5 Major Depressive Disorder and Its Specifiers in the United States. JAMA psychiatry, 75(4), 336–346. https://doi.org/10.1001/jamapsychiatry.2017.4602

Lindvall Dahlgren, C., Wisting, L., & Rø, Ø. (2017). Feeding and eating disorders in the DSM-5 era: a systematic review of prevalence rates in non-clinical male and female samples. Journal of eating disorders, 5, 56. https://doi.org/10.1186/s40337-017-0186-7

McMaster, C. M., Wade, T., Franklin, J., & Hart, S. (2020). Development of consensus-based guidelines for outpatient dietetic treatment of eating disorders: A Delphi study. The International journal of eating disorders, 53(9), 1480–1495. https://doi.org/10.1002/eat.23330

Sadowsky J. (2021). Before and After Prozac: Psychiatry as Medicine, and the Historiography of Depression. Culture, medicine and psychiatry, 45(3), 479–502. https://doi.org/10.1007/s11013-021-09729-2

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Management Plan Template:

(Every section of your management plan must have in-text citations to support your plan).

Instructions: Answer the following questions (Complete the SOAP note)

– Why? What made you select each one as a primary and differential diagnosis?

– How did you rule out each differential diagnosis? This would be a good area to include references.

Primary Diagnosis: Anorexia Nervosa: Binge Eating/Purging (F50.02)

Differential Diagnosis:
1. Anorexia: Restricting type (F50.01)
2. Bulimia Nervosa (F50.2)
3. Major Depressive Disorder (F32.9)

Additional laboratory and diagnostic tests May be necessary to establish or evaluate a condition. Some tests, such as MRI, may require prior authorization from the patient’s insurance carrier.

– Diagnostic tests and results used to determine the diagnosis: (Explain)
CBC, BMP, ECG, etc.

Consults: referrals to specialists, therapists (physical, occupational), counsellors, or other professionals. If you are sent to the hospital, what orders would you write for direct admission?

Therapeutic modalities: pharmacological and nonpharmacological management. Give specific medications, dosing and duration. Include anticipated therapeutic modalities/symptomatic treatment for patients if they are sent to ED or directly admitted.

Health Promotion: Address risk factors as appropriate. Consider age-appropriate preventive health screening.

Patient education: Explanations and advice given to patient and family members.

Disposition/follow-up instructions: when the patient is to return sooner and when to go to another facility such as the emergency department, urgent care centre, specialist, or therapist.

Scholarly references (minimum of 3, timely, that prove this plan follows the current standard of care).