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332 Resolutions Wild‐type chickenpox, caused by the varicella zoster virus, is an easily identifiable disease. It is typically a maculopapular rash with vesicles, characteristically with lesions beginning on the trunk and spreading distally. The lesions may be in different stages of healing. It is currently recom-mended that children get 2 doses of the VZV vaccine. It has been estimated that approximately 7% of children who received only one dose of the VZV vaccine developed VZV over a 10‐year period, while only 2. 2% of children who received 2 doses developed VZV. In cases of breakthrough VZV, there are often less than 50 lesions, and many times there are less than 10 lesions. Furthermore, in breakthrough varicella, the rash may be primarily maculopapular with few, if any, vesicles. Typically, the unvaccinated child who contracts chickenpox will have an average of 300-400 vesi-cles and, perhaps, up to 1000 vesicles. It is important for the health care provider to understand that breakthrough varicella infections present differently, and much less acutely, than classic wild‐type VZV. If the history and physical presentation of the rash are consistent with VZV, no diagnostic tests are usually done. What is the plan for treatment, referral, and follow‐up care? Breakthrough VZV is a self‐limiting disease. The management is primarily supportive: diphenhy-dramine for itching and acetaminophen for fever and pain management. Oatmeal baths can be used to ameliorate itching. Aubrey should stay home from school until all of her lesions have dried and crusted. Aspirin should be avoided due to the risk of Reye syndrome in children. Acyclovir will not be helpful in Aubrey's case because her rash appeared more than 24 hours before she presented to the office. The health care provider should inquire about the vaccination status of Aubrey's brother and whether her parents have positive VZV titers, indicating immunity to the virus. Does this patient's psychosocial history affect how you might treat this case? Aubrey has no psychosocial characteristics that would alter management of her breakthrough VZV. What if the patient lived in a rural setting? If Aubrey lived in a rural setting, the consideration of tick‐borne disease might be higher on the differential. However, living in an urban or suburban environment, excursions into rural places need to be considered. Are there any demographic characteristics that might affect this case? If Aubrey were immunocompromised or had contact with an immunocompromised patient, her VZV would be treated more aggressively. REFERENCES AND RESOURCES Dubey, V., & Mac Fadden, D. (2019). Disseminated varicella zoster virus infection after vaccination with a live attenuated vaccine. CMAJ: Canadian Medical Association Journal, 191, E1025-E1027. Harpaz, R., & Leung, J. (2019). The epidemiology of herpes zoster in the United States during the era of vari-cella and herpes zoster vaccines: Changing patterns among older adults. Clinical Infectious Diseases, 69, 345-347. Lopez, A. S., La Clair, B., Buttery, V., Zhang, Y., Rosen, J., Taggert, E., . . . Marin, M. (2019). Varicella outbreak surveillance in schools in sentinel jurisdictions, 2012-2015. Journal of the Pediatric Infectious Diseases Society, 8, 122-127. Ludman, S., Powell, A., Mac Mahon, E., Martinez‐Alier, N., & du Toit, G. (2018). Increased complications with atopic dermatitis and varicella‐zoster virus. Professional Nursing Today, 22, 27-31. Marin, M., Leung, J., & Gershon, A. (2019). Transmission of vaccine‐strain varicella‐zoster virus: A systematic review. Pediatrics, 144, 1-9. Weinberg, A., Popmihajlov, Z., Schmader, K. E., Johnson, M. J., Caldas, Y., Salazar, A. T., . . . Levin, M. J. (2019). Persistence of varicella‐zoster virus cell‐mediated immunity after the administration of a second dose of live herpes zoster vaccine. Journal of Infectious Diseases, 219, 335-338.
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333 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION What are the top three differential diagnoses in this case and why? Bacterial conjunctivitis: Acute bacterial conjunctivitis typically presents with complaint of unilateral eye redness, although it can be bilateral, along with purulent discharge. Mild discomfort may be reported, but pain and itch are generally absent. Discharge is copious and often yellow, green, or white in coloration. Patients may report history of “crusty, eyelids being stuck closed or glued together” in the morn-ings. This history detail was previously highly predictive of bacterial conjunctivitis. However, caution is advised relying on this specific detail, as several types of conjunctivitis present with variations of discharge leading to formation of dried crusts overnight. An important detail that can assist in differentiating bacterial conjunctivitis from other etiologies is the presence of purulent discharge continuing throughout the day, often reappearing minutes after cleansing/wiping eye. Upon examination, the conjunctiva will appear injected and the inner canthus (inner corner of eyes), along with lid margins, may reveal purulent discharge. Vision remains normal. Common pathogens of bacterial conjunctivitis are Staphylococcus aureus, Streptococcus pneumonia, Haemophilus influenza, and Moraxella catarrhalis. Transmission is facilitated by contact with patient's discharge and or contaminated surfaces. Bacterial conjunctivitis is considered extremely contagious. Viral conjunctivitis: Viral conjunctivitis typically presents with complaint of unilateral redness, watery to mucoserous discharge, and burning or sandy sensation. Itch is not commonly reported. Although symptoms can remain unilateral, the second eye often becomes involved within 48 hours of initial onset. Often but not always, the occurrence of a viral prodrome precedes or shortly follows emergence of con-junctivitis, with spontaneous resolution between 1 to 2 weeks. Associated symptoms may include pharyngitis, upper respiratory infection, congestion, and fever. Upon examination, the conjunctiva will appear injected without presence of purulent discharge. Discharge often appears watery or mucoserous. Excessive tearing may be present along with an enlarged and tender pre‐auricular node. Further inspection directed to the tarsal conjunctiva may reveal follicular prominence or a “bumpy” appearance. Vision remains normal. Case 4. 3 Red Eye
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334 Resolutions Common viral pathogens are adenovirus, enterovirus, and their subtypes. Transmission is facili-tated by direct contact with the patient and their secretions, as well as contaminated fomites. Viral conjunctivitis is considered highly contagious. Treatment is supportive with application of cool compress and artificial tears. Antibiotics are not indicated for treatment of viral conjunctivitis. Allergic conjunctivitis: Allergic conjunctivitis typically presents with bilateral injection, watery drainage, and the distinct symptom of itch, which is not commonly present with bacterial and viral etiologies. Patients often report history of atopy whether seasonal rhinitis, eczema, asthma, or to specific allergens such as pet dander. Reports of prior exposure to allergens in combination with symptom of itch can aid in distinguishing etiologies. Associated symptoms would be consistent with common allergy symptoms of congestion, rhinorrhea, sneezing. Upon examination, the conjunctiva will appear injected with copious epiphora (tearing). Discharge will be watery, thin, and often stringy. Similar to viral etiologies, follicular prominence to the tarsal conjunctiva may be present. In select presentations conjunctival edema, chemosis, can be noted. Vison remains normal. Allergic conjunctivitis is caused by an allergen‐induced, Immunoglobulin E (Ig E)‐mediated hypersensitivity response. Treatment hinges on reducing exposure to known allergens and over‐the‐counter antihistamine medications. Topical ophthalmic drops can be added for more moderate to severe responses. What are the diagnostic tests required in this case and why? A diagnosis of conjunctivitis is typically clinical through process of exclusion. Important aspects of history and examination include ensuring normal vision acuity and ruling out any recent history of trauma. Any vision‐threatening findings should warrant further evaluation before a diagnosis of conjunctivitis is made. Diagnostic testing is not routinely ordered. Cultures to identify bacteria and antibiotic sensi-tivity are reserved for more complex presentations, such as patients with compromised immune systems, contact lens wearers, neonates, and treatment failures. What is the plan of treatment? Bacterial conjunctivitis is frequently a self‐limited process, but topical antibiotics, either drops or ointment, are recommended in order to provide quicker recovery, limit the spread of infection, and reduce the risk of further complication. Topical antibiotics are preferred due to their direct applica-tion to the ocular surface, which ensures a higher concentration of delivered medication. Empirical treatment with broad‐spectrum antibiotics, such as polymyxin B sulfate and trimethoprim sulfate, 0. 3% gentamycin, 0. 5% erythromycin, and 0. 3% tobramycin, can be utilized, as comparative studies have not shown one ophthalmic antibiotic to be superior to another. Ointment is preferred over drops as a treatment consideration for younger children, as it may be difficult to administer drops. Ointments can have a blurring effect and, as a result, are not recommended for adults who require clear vision for activities of daily living. Medication choice should focus on cost effectiveness and local bacterial resistance pattern, if known. Are there any standardized guidelines that should be used to treat this case? If so, what are they? The American Academy of Ophthalmology created a guideline on preferred practice patterns of conjunctivitis. The guideline showcases aspects of initial history collection through comprehensive medical examination. Referral guidelines are also presented. This guideline can be found at http://www. aao. org. What are the plans for follow‐up care and referral? As mentioned previously, bacterial conjunctivitis is often self limiting with use of antibiotic medi-cation serving to shorten the clinical course, limit the spread of infection, and reduce the risk of
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Red Eye 335 complications. If symptoms do not resolve or improve within 1 week of treatment, further evalua-tion is warranted. Educational guidance focusing on decreasing transmission through meticulous hand hygiene and avoidance of sharing personal objects should be provided to the patient/family. Referral to ophthalmology is warranted for any history and or findings related to sight‐threatening conditions. Examples include decreased visual acuity, significant photophobia, severe eye pain, suspected foreign body, recurrent episodes, or corneal opacity. Are there any special examination and or treatment considerations that may affect this case? Regarding this case, the patient reported wearing glasses. In presentations of conjunctivitis it is important to inquire about contact lens use. There are recommendations as to the treatment of bac-terial conjunctivitis in those who wear contact lenses. Soft, extended‐wear lenses carry a greater risk of pseudomonal keratitis. Findings include acute red eye, discharge, and ulcerative keratitis marked by an inability to open or keep open the eye due to severe foreign body sensation. If kera-titis is ruled out and bacterial conjunctivitis is diagnosed, patients may be treated with topical anti-biotics. Due to the risk of pseudomonas, fluoroquinolones are the medications of choice. It is recommended that contact lens use be discontinued until 24 hours post resolution of discharge. REFERENCES AND RESOURCES American Academy of Opthalmology Cornea/External Disease Panel, Preferred Practice Patterns Committee. (2018). Conjunctivitis. San Francisco, CA: American Academy of Opthalmology (AAO). Cronau, H., Kankanala, R. R., & Mauger, T. (2010). Diagnosis and management of red eye in primary care. American Academy of Family Physicians, 81(2), 137-144. Eltis, M. (2011). Contact‐lens‐related microbial keratitis: Case report and review. Journal of Optometry, 4(4), 122-127. Hovding, G. (2008). Acute bacterial conjunctivitis. Acute Opthalmologica, 86(1), 5-17. Spering, K. A. (2011). CME/CE: Therapeutic strategies for bacterial conjunctivitis. Clinical Advisor, 14(8), 31-40.
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337 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION Which diagnostic or imaging studies should be considered to assist with or con-firm the diagnosis? When evaluating a sore throat, several tests may be helpful to determine the cause of the ill-ness and to decide the treatment plan. If group A beta‐hemolytic streptococci (GABHS) is sus-pected, a rapid antigen detection test (rapid strep test) and a throat culture should be performed. Both tests are needed because the rapid test provides a preliminary result, while the culture provides the final result after 48 hours. The benefits of using the rapid strep test along with the culture are avoiding unnecessary antibiotic usage and treating the patient in an appropriate and timely manner. If the Epstein‐Barr virus (EBV) is suspected, a CBC, monospot, and LFTs should be ordered. If other viral etiology is suspected, diagnostic testing is not needed. Imaging studies are usually not needed unless a retropharyngeal, parapharyngeal, or peritonsillar abscess is suspected. In that case, a plain lateral neck film may be ordered as an initial screening tool. What is the most likely differential diagnosis and why? GABHS: Several differential diagnoses should be considered when evaluating a sore throat. Viral etiologies cause 40% of cases of sore throats, with enteroviruses, adenoviruses, and EBV being the most common. Bacterial pathogens cause 30% of sore throats, which are usually caused by GABHS, although other pathogens such as Staphylococcus aureus or Haemophilus influenzae should also be considered. Pharyngitis caused by the fungus Candida albicans is another differential diagnosis that should be considered, especially for immunosuppressed individuals. Other more urgent diagnoses such as peritonsillar abscess or retropharyngeal abscess need to be ruled out. Given the patient's history of fever of 101°F, sore throat, and headache, along with the physical exam findings of ery-thematous tonsils with exudates, palatal petechiae, and cervical adenopathy, the most likely diag-nosis is GABHS. In addition to this patient's classic symptoms, many children may also experience nausea or vomiting and/or a scarlatiniform rash. Case 4. 4 Sore Throat
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338 Resolutions What is the plan for treatment, referral, and follow‐up care? Penicillin or amoxicillin is the drug of choice for treating GABHS. They are effective and do not contribute to antibiotic resistance and the complication of rheumatic fever will be avoided. In penicillin‐allergic patients, r ecommended courses of treatment include narrow‐spectrum cephalo-sporins (cephalexin, cefadroxil), clindamycin, azithromycin, or clarithromycin. Whether the pharyngitis is viral or bacterial in origin, the use of antipyretics for pain and fever is beneficial, as ar e other symptomatic treatments such as increasing liquid intake. Referral to an ear, nose, and throat (ENT) specialist is only necessary should complications arise. Follow‐up care is needed if the patient's symptoms worsen or persist for more than 48 hours while on antibiotics. Does this patient's psychosocial history affect how you might treat this case? There is nothing in this patient's psychosocial history that would affect how this case is treated. What if the patient lived in a rural setting? No changes in diagnosis or treatment are required if the patient lives in a rural setting. However, if the patient has emigrated from or traveled to a high‐risk area for diphtheria, other testing and treatment should be considered. Are there any demographic characteristics that might affect this case? There is no racial or ethnic predisposition for the development of GABHS. Regarding age, the majority of children who develop GABHS are between 5 and 10 years of age. Socioeconomic status is not known to be associated with GABHS. REFERENCES AND RESOURCES Berkley, J. (2018). Management of pharyngitis. Circulation, 138, 1920-1922. Farrer, F. (2018). OTC treatments for tonsillitis and pharyngitis. Professional Nursing Today, 22, 8-11. Homme, J. (2019). Acute otitis media and group a streptococcal pharyngitis: A review for the general pediatric practitioner. Pediatric Annals, 48, e343-e348. Norton, L., Lee, B., Harte, L., Mann, K., Newland, J., Grimes, R., & Myers, A. (2018). Improving guideline‐ based streptococcal pharyngitis testing: A quality improvement initiative. Pediatrics, 142, 1-9.
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339 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? Selected lab evaluations help to convince parents that the child is physically healthy and that other conditions may be important to consider. A CBC and lead screening assures that there is no anemia, infection, or elevated lead level. Hyperactive thyroid would be very unlikely to pre-sent this constellation of symptoms and need not be obtained unless the mother is very concerned because of her own thyroid disorder. Vision and hearing screening are essential to assure that Jason has intact sensory systems so he is able to respond appropriately to directions and facial cues. Jason's hearing screen was normal. Vanderbilt ADHD screening indicated no concerns with inattentiveness or combined‐type ADHD. Information gathered from the school suggested that Jason started the year as a capable student who has begun to lag behind his peers, especially in reading and social skills. Jason's mother completed the Pediatric Symptom Checklist. Scoring revealed that Jason has trouble obeying his teacher, is often irritable and angry, fights with other children, does not listen to rules, does not understand other people's feelings, blames others for his troubles, teases others, and refuses to share. What is the most likely differential diagnosis and why? Oppositional defiant disorder: To arrive at a working diagnosis, much more information needs to be gathered from Jason's teacher and from standardized screening tools and possibly school assessments of learning issues. Based on the test results and further history from his mother and teacher, it appears that Jason meets the DSM‐5 diagnostic criteria for oppositional defiant disorder (ODD). This diagnosis is mor e likely than depression. Jason's behavior is more extreme than his peers', and it interferes with his social and academic development. Jason also has numerous risk factors for this disorder, including financial problems in the family, family instability, a parent with a substance abuse disor der, parents with a history of ADHD, lack of positive parental involvement, and inconsis-tent discipline. Case 4. 5 Disruptive Behavior
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340 Resolutions What is the plan of treatment? Discuss the diagnosis with his mother and father. Reinforce that this is a manageable condition and that primary care will provide support to the family in their efforts to make change. Discuss that early intervention is critical and has the greatest possibility of preventing ODD from progress-ing to conduct disorder. Address parental concerns and assure them that effective, consistent discipline can make significant improvements. Recommend parent‐focused discipline literatur e such as 1‐2‐3 Magic by Thomas Phelan. Refer for parent‐management training such as Russell Barkley's Par ent Management Training or Ross Greene's Collaborative Problem‐Solving. Refer to conduct clinic, if available in community or university setting. Refer for family therapy or individual play therapy for Jason. Consider social skills training if peer relationships deteriorate. Encourage close communication with his teacher to assure consistent approaches to behavior changes. If comorbid ADHD develops at a later time, stimulant medications may be helpful. What is the plan for follow‐up care? Follow up in the primary care setting to reinforce strategies learned in therapy and to offer continued support for family efforts. Encourage the grandparents' participation in visits so they will utilize the same approaches that the parents are learning. Are there any demographic factors that might affect this case? This condition can occur in any socioeconomic or racial group. Risk factors are noted above. REFERENCES AND RESOURCES de la Osa, N., Penelo, E., Navarro, J., Trepat, E., & Ezpeleta, L. (2019). Prevalence, comorbidity, functioning and long‐term effects of subthreshold oppositional defiant disorder in a community sample of preschoolers. European Child & Adolescent Psychiatry, 28, 1385-1393. El Ouardani, C. (2017). Innocent or intentional?: Interpreting oppositional defiant disorder in a preschool mental health clinic. Culture, Medicine & Psychiatry, 41, 94-110. Katzmann, J., Görtz‐Dorten, A., & Döpfner, M. (2018). Child‐based treatment of oppositional defiant disorder: Mediating effects on parental depression, anxiety and stress. European Child & Adolescent Psychiatry, 2, 1181-1192. Miller, R., Gondoli, D., Gibson, B., Steeger, C., & Morrissey, R. (2017). Contributions of maternal attention‐ deficit hyperactivity and oppositional defiant disorder symptoms to par enting. Parenting: Science & Practice, 17, 281-300. Ter‐Stepanian, M., Martin‐Storey, A., Bizier‐Lacroix, R., Déry, M., Lemelin, J., & Temcheff, C. (2019). Trajectories of verbal and physical peer victimization among children with comorbid oppositional defiant problems, conduct problems and hyperactive‐attention problems. Child Psychiatry & Human Development, 50, 1037-1048. NOTE: The author would like to acknowledge Patricia Ryan‐Krause, MSN, APRN, who co‐authored this case in the first edition of this book.
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341 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION What diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? The nasal pharyngeal swab for direct fluorescent antibody (DFA) was positive for influenza type A. Oxygen saturation is 94%, which is an indication of poor exchange of oxygenation. Chest X‐ray was negative for pneumonia; and there is no peribronchial cuffing, which is more often seen in bronchiolitis. There was no mediastinal shift or collapsed lung seen with foreign body aspiration. What are the top differential diagnoses and why? Foreign body aspiration: Always consider when seeing a patient with acute wheezing, even if they have a diagnosis of asthma. Bronchiolitis: Consider if the child is less than 2 years of age and develops wheezing with a viral illness. Asthma: Consider if there is a family history of asthma, allergies and/or eczema, and recurrent episodes of wheezing. GERD: Children can aspirate and symptoms can mimic asthma. What is the most likely differential diagnosis and why? Asthma: Asthma is one of the most prevalent chronic diseases facing American children today. The diagnosis of asthma is based on the exclusion of alternative diagnoses, as well as the history of recurr ent and transient airflow obstructive symptoms, the patient's subjective experience of symptoms, and objective clinical manifestations. These criteria will vary among patients and in the same patient over time. The important signs and symptoms needed to diagnose asthma include (1) recurrent wheeze, (2) improvement of symptoms after treatment with a bronchodilator, (3) recurrent cough or shortness of breath, (4) impaired peak flow performance when compared to the expected value based on height and age, and (5) exclusion of alternative differential diagnoses. A differential diagnosis still requires consideration in any patient who is wheezing, including one with a known diagnosis of asthma and a history of exacerbations. Several conditions may lead to a presentation similar to acute asthma. Some of these include congestive heart failure, vocal cord Case 4. 6 Cough and Difficulty Breathing
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342 Resolutions dysfunction, gastroesophageal reflux, acute bronchitis or bronchiolitis, pulmonary emboli, or the presence of a foreign body. After the diagnosis of asthma has been made, the severity of the patient's asthma can be classi-fied, based in part on the frequency of symptoms, findings on physical exam, and severity of exac-erbations. Severity ranges from intermittent to severe persistent, depending on the frequency of daytime symptoms, nighttime symptoms, interference with normal activity, lung function, and number of exacerbations requiring oral corticosteroids in the past year. Accurate classification of asthma severity is critical because treatment goals and pharmacological management are based on the individual's asthma classification. Because individuals may manifest different symptoms over time, periodic reevaluation and adjustment of the patient's medications are necessary. Information gathered during the initial asthma assessment will serve as baseline data, by deter-mining the patient's respiratory status and the severity of the current exacerbation. After an inter-vention is implemented, repeat assessments are recommended. These serial assessments can be compared against the baseline data so that trends in the patient's response to treatment can be revealed. Next, the health care provider can assess the severity of the current exacerbation through auscultation of the lung fields, noting the movement of air and presence of abnormal breath sounds. Treatment should be initiated as soon as the diagnosis of an asthma exacerbation is confirmed. What is the plan of treatment? An asthma exacerbation should be treated with an early intensification of an inhaled beta2‐agonist and the administration of oxygen and an oral or systemic steroid when medically necessary. The inhaled beta 2‐agonists, known as quick‐relief or rescue medications, should be given to all patients regardless of the severity of their exacerbation. Exacerbation therapy should begin with up to 3 treatments of a short‐acting beta 2‐agonist, given at 20‐minute intervals over an hour. The minimum dose should be 2. 5 mg, or 0. 15 mg/kg of body weight. The alternative is to give 2-6 puffs of alb-uterol, 90 mcg/puff by metered dose inhaler (MDI) with a spacer attachment. However, if no improvement is demonstrated after the initial treatment, the exacerbation severity can be classified as moderate or severe, and a steroid should be given in conjunction with the bronchodilator. The recommended child dose for an oral steroid such as prednisolone is a loading dose of 2 mg/kg of body weight, followed by 2 mg/kg/day 1 to 2 times a day (maximum dose of 60 mg/day). Additionally, an inhaled beta 2‐agonist should be given every 4 hours as needed for wheezing. What is the plan for follow‐up care? After the treatment goals have been met, the patient can continue therapy and monitoring inde-pendently at home with a short‐term intensification of their treatment. For most patients, this means an increase in the frequency of beta 2‐agonist use and the addition of a systemic steroid. Patients should not leave the health care setting without receiving educational information, an asthma action plan, a follow‐up appointment to take place within 3 days of the exacerbation, and a clear understanding of how to contact the provider should their condition deteriorate. It is recom-mended that children who have experienced an exacerbation should follow up with their health care provider 2-3 days after the acute episode to (1) monitor the response to treatment, (2) encourage continued patient compliance with their medication regimen, (3) prevent a relapse of symptoms, and (4) provide an educational review of information discussed during previous visits. Are any referrals needed at this time? No. The provider should consider a referral to a pulmonologist or allergist if symptoms cannot be managed using standard approaches or if the provider thinks that there may be additional factors that complicate the case. Are there any standardized guidelines that should be used to assess or treat this case? The following approach to acute asthma treatment is based on the findings of the National Heart, Lung, and Blood Institute Expert Report Panel (2007) and the Global Initiative for Asthma (GINA)
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Cough and Difficulty Breathing 343 (2019). This information is meant to serve as a guide to exacerbation treatment. Strict adherence to general guidelines should never supersede individual response to therapy, which is monitored through patient report of symptoms, continuous skilled assessment, and accurate data collection. Adjustments may need to be made initially and ongoing during treatment depending on the patient's prior exacerbation history, present respiratory abilities, and response to treatment. The lowest and simplest dosing regimen that effectively controls the individual's acute asthma should be selected to encourage patient compliance. REFERENCES AND RESOURCES Albassan, S., Hattah, Y., Bajwa, O., Bihler, E., & Singh, A. C. (2016). Asthma. Critical Care Nursing Quarterly, 39(2), 110-123. Global Initiative for Asthma (GINA). (2019). 2019 GINA Report: Global strategy for asthma management and prevention. Retrieved from: https://ginasthma. org/ Meadows‐Oliver, M., & Banasiak, N. C. (2005). Asthma medication delivery devices. Journal of Pediatric Health Care, 19(2), 121-123. National Asthma Education & Prevention Program. (2007). Expert panel report 3: Guidelines for the diagnosis and management of asthma. Bethesda, MD: National Institute of Health. Voorend‐van Bergen, S., Vaessen‐Verberne, A. A., de Jongste, J. C., & Pijnenburg, M. W. (2015). Asthma control questionnaires in the management of asthma in children: a review. Pediatric pulmonology, 50(2), 202-208. Zahran, H. S., Bailey, C. M., Damon, S. A., Garbe, P. L., & Breysse, P. N. (2018). Vital signs: Asthma in chil-dren—United States, 2001-2016. Morbidity and Mortality Weekly Report, 67(5), 149.
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345 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? Based on the history and physical examination, a radiograph of the left arm and clavicle is needed to rule out a fracture. What is the most likely differential diagnosis and why? Suspected child physical abuse: Physical abuse of Jair should be considered. He has a physical injury and his parents are providing inconsistent stories about the origin of his injuries. Additionally, Jair has injuries (bruising and an abrasion) on the right side of his body—the side opposite of his fall. Abused children often present with multiple types of injuries (bruising, abrasions, and fractures). Multiple types of injuries decrease the likelihood of a single medical condition being the cause of the injuries. What is the plan for treatment, referral, and follow‐up care? Refer this child to the local emergency department for further evaluation, consultation with a social worker, and possible in‐patient admission. Call child protective services to r eport a suspected case of child physical abuse. Allow the parents to verbalize their concerns about their baby's health. Are there any referrals needed? A referral to the local child protective services agency is warranted. Health care providers can receive help and resources from the Childhelp National Child Abuse Hotline. The Childhelp National Child Abuse Hotline is dedicated to the prevention of child abuse. The hotline is staffed 24 hours a day, 7 days a week with professional crisis counselors who can provide assistance in over 170 languages through the use of interpreters. They can be reached at https://www. childhelp. org/hotline/ or by telephone at 1‐800‐4‐A‐CHILD. Case 4. 7 Left Arm Pain
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346 Resolutions Does the patient's psychosocial history impact how you might treat him? Adolescent mothers have been shown to exhibit higher rates of child abuse than do older mothers. Other psychosocial factors such as lower economic status, lack of social support, and high stress levels may also contribute to the link between adolescent parents and child abuse (Children's Bureau, n. d. ). REFERENCES AND RESOURCES Children's Bureau. (n. d. ). Teen parenting. https://www. childwelfare. gov/topics/can/factors/parentcaregiver/ teen/ Fréchette, S., Zoratti, M., & Romano, E. (2015). What is the link between corporal punishment and child physical abuse? Journal of Family Violence, 30, 135-148. Ho, G., Gross, D., & Bettencourt, A. (2017). Universal mandatory reporting policies and the odds of identifying child physical abuse. American Journal of Public Health, 107, 709-716. Johnson, M. (2017). Imaging and diagnosis of physical child abuse. Radiologic Technology, 89, 45-67. Teeuw, A., Kraan, R., Rijn, R., Bossuyt, P., Heymans, H., & van Rijn, R. (2019). Screening for child abuse using a checklist and physical examinations in the emergency department led to the detection of more cases. Acta Paediatrica, 108, 300-313.
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347 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION Which diagnostic or imaging studies should be considered to assist with or con-firm the diagnosis? An EEG may reveal altered consciousness during night terror episodes. An EEG will also help to diagnose nocturnal seizures. Polysomnography can help to diagnose parasomnias such as sleep-walking, nightmares, and night terrors. An MRI may show if a brain lesion is causing the problem of night awakening and screaming. A CT scan and skull radiographs are usually not helpful in the testing for sleep disturbances. What is the most likely differential diagnosis and why? Night terrors: Nightmares happen during REM (rapid eye movement) sleep. Children with nightmares awaken and will recall having vivid dreams. A child who is having a nightmare is fully awake and often will seek comfort from a caregiver. Nocturnal seizures, which occur only during sleep, can cause the victim to cry, scream, walk, run about, or curse. Like other seizures, these are usually treated with medication. With nightmares, the child may also scream and cry. Night terrors (sometimes known as sleep terrors) occur in stage IV of the sleep cycle. Stage IV is also known as slow‐wave sleep (SWS) and usually occurs during the first third of the night. Although appearing to be awake, children experiencing a night terror are still in a light sleep. A child suffering from a night terror will be unable to be calmed by a caregiver. Each episode will generally last for less than 5 minutes, although some children experience multiple terrors each night. A child who experiences night terrors will usually have no memory of the event in the morning, while a child with a nightmare may or may not have a memory of the dream but will almost certainly remember being awake. Night terrors are the most likely diagnosis when taking the history and physical examination into account. What is the plan for treatment, referral, and follow‐up care? Several factors have been theorized to contribute to night terrors, such as lack of a regular bedtime, a full bladder, and extra noise or lights in the sleeping environment. A treatment plan would encompass education on each of these aspects. Daniel's lack of a set bedtime may contribute to his being overtired but neither clinical exam nor history suggest that he struggles with daytime fatigue or lack of energy. However, the health care provider should question the mother about this Case 4. 8 Nightmares
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348 Resolutions possibility further. A full bladder at the time of a night terror cannot be ruled out and should also be further explored. It should be noted that Daniel shares a bedroom with his younger brother. It is unknown whether the brother uses a nightlight, snores, or otherwise contributes to environmental pollution through music or television. When providing education, parents should be reminded that the night terror episodes, while disturbing to them, are not remembered by the child. When a child is experiencing a night terror, a parent should check on him to confirm his safety. Although difficult, parents are discouraged from picking up the child or providing other comfort measures. For the child experiencing a night terror, consoling from a parent can cause greater distress and result in full awakening. The health care provider may suggest that Daniel's mother maintain a sleep diary and observe him throughout several night terror episodes, noting the amount of time after he falls asleep that the night terror begins. After Daniel's sleep‐wake pattern is determined, his mother should wake him up approximately 15 minutes before the usual time of the night terror and keep him awake and out of bed for a full 5 minutes. This process should continue for approximately for 5-10 days. By waking up the child before the night terror actually begins, the sleep cycle is consistently dis-turbed and is then able to be reestablished—typically without the resumption of the night terrors. This may help to break the disruptive sleep pattern that has resulted in the night terrors. Upon awakening the child, the parents can also coax the child to use the bathroom if a full bladder is a suspected contributor to the night terrors. Prior to sleep, there are other steps that parents can take to reduce the occurrence of night ter-rors. A consistent bedtime and sleep hygiene routine may reduce the occurrence of night terrors. Daniel's mother can begin by establishing a consistent time for bed along with a regular bedtime routine. Maintaining quiet time without sudden unsettling noises near bedtime may minimize some of the external stimuli that are thought to contribute to night terrors. Since night terrors might be triggered by a full bladder, having Daniel use the toilet prior to bedtime and even during the course of the night might be beneficial in reducing reoccurrence of night terrors. In extreme cases of night terrors, benzodiazepines (known to suppress the stage IV level of deep sleep) have been prescribed, although this is not a standard recommendation. Pharmacological options are contro-versial and are generally not considered in children under the age of 7 years. Alternative options such as hypnosis, biofeedback, and various relaxation techniques have been used with some suc-cess to reduce or eliminate occurrence of childhood night terrors. Calming music or bedtime stories may also assist with the reduction of night terrors. Follow‐up can be done by telephone in 1-2 weeks to ascertain if the recommendations to reduce the night terrors have been effective. Daniel's family should also follow up in the office if Daniel exhibits drooling, jerking, or stiffening of the body during the night terror. If the episodes have continued without improvement, consider referring Daniel to a sleep specialist and for a polysom-nography test to assist with the diagnosis of a parasomnia. Does this patient's psychosocial history affect how you might treat this case? Daniel lives in a home with several family members. With 3 generations of family members in the home, bedtime may not be a quiet time. Including Daniel's grandmother in the treatment plan may also help to reduce or lessen the occurrence of night terrors. What if the patient lived in a rural setting? The treatment of night terrors would not vary based on residence in a rural area. However, if Daniel's night terrors continued and he needed to be referred to a specialist, the family might have difficulty accessing specialty services if they do not reside near a major medical center that employs a sleep specialist. Are there any demographic characteristics that might affect this case? Children between the ages of 3 and 5 years of age are most likely to experience night terrors with the prevalence decreasing with increasing age. There is no clear indication regarding gender and
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Nightmares 349 the occurrence of night terrors. Some studies say that the occurrence is nearly equal. Studies show that 49% of affected children were boys, and 51% were girls. Others studies report that childhood night terrors occur more frequently in boys. REFERENCES AND RESOURCES Ellington, E. (2018). It's not a nightmare: Understanding sleep terrors. Journal of Psychosocial Nursing & Mental Health Services, 56, 11-14. Moreno, M. (2015). Sleep terrors and sleepwalking: Common parasomnias of childhood. JAMA Pediatrics, 169, 704-704. Petit, D., Pennestri, M. ‐H., Paquet, J., Desautels, A., Zadra, A., Vitaro, F., . . . Montplaisir, J. (2015). Childhood sleepwalking and sleep terrors: A longitudinal study of prevalence and familial aggregation. JAMA Pediatrics, 169, 653-658. Richarde, S. (2018). Night terrors and sleepwalking in children and adults: Pathophysiology and potential therapies. Journal of the American Herbalists Guild, 16, 59-67. NOTE: The author would like to acknowledge the contribution of Allison Grady, MSN, RN to this case in the first edition of this book.
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351 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION What are the top three differential diagnoses for this patient? What tests would help to confirm your suspicions? Given the vagueness of the symptoms—essentially several months of diarrhea and abdominal pain— there should be many potential diagnoses on your list of differentials. Initially, irritable bowel syn-drome (IBS), celiac disease, functional abdominal pain, food allergy, failure to thrive, autoimmune disease, and eating disorder all come to mind. These are some of the first thoughts because Katie is having ongoing, but still relatively new, abdominal symptoms that are affecting her quality of life. This list of possibilities includes gastrointestinal focus but also includes other systems such as immune, genetic, and psychological. Important pieces of the patient's history that might help to narrow the possibilities include that Katie expanded her palate around the same time that her growth began to slow, which might point more to celiac disease, food allergy, or autoimmune disease and may suggest against an eating disorder. Taking a careful history can guide the provider by revealing potential clues and new information about the condition. If the patient has identified any stressful triggers (e. g., situations at home or school) or changes to bowel patterns (for example, periods of diar-rhea and then periods of constipation), this might point more toward irritable bowel syndrome (IBS). Skin changes such as hives, eczema, or dermatitis herpetiformis or gastrointestinal complaints around mealtimes might suggest food allergy or celiac disease. A detailed and specific family history in combination with information about any recent illnesses that Katie has experienced might help to better understand the risk of an autoimmune or genetic disease. Katie's diagnosis, however, is celiac disease. Although celiac is only present in less than 2% of the population (Lebwohl, Sanders, & Green, 2018), the main symptoms are gastrointestinal in nature, family history of a second‐degree relative with the condition (Fedewa et al., 2019, in press), and a mother with a history of multiple miscarriages all raise the suspicion of celiac disease (Nahar & Avani, 2019) (see Table 4. 9. 1). Celiac disease: Celiac disease (CD) has been described as “a chronic, small‐intestinal immune‐mediated enteropathy initiated by exposure to dietary gluten in genetically predisposed individuals and characterized by specific autoantibodies against tissue transglutaminase 2, endomysium, and/or deamidated gliadin Case 4. 9 Gastrointestinal Complaint
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352 Resolutions peptide” (Leonard, Sapone, Catassi, & Fasan, 2017, p. 647). In more conventional terms, celiac disease is an autoimmune condition that is triggered by the environmental exposure to gluten, which is found in wheat, rye, and barley. The affected individual develops autoantibodies to the gluten, which in turn cause inflammation and small villous atrophy of the small bowel. Over time, this recurrent injury to the small bowel can result in chronic inflammation, increased risk for infection, and numerous other anatomical and clinical changes that interfere with quality of life and threaten overall health. Celiac disease typically presents with gastrointestinal symptoms but the effects of the disease is not limited to this corporal system. Nongastrointestinal features such as skin rash (dermatitis her-petiformis), fatigue, anemia, dental abnormalities, failure to thrive, and nutritional abnormalities also are common presenting symptoms for patients with celiac disease (Leonard et al., 2017; Khatib, Baker, Ly, Kozielski, & Baker, 2016). In fact, most patients with celiac disease have zinc, folate, and vitamin D deficiencies (Mager et al., 2019). Celiac is most often diagnosed in the fourth to sixth decades of life, but can be present from any time that gluten ingestion occurs—often, shortly after the introduction of solids in infancy (U. S. Preventive Services Task Force, 2017). The European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHN) released a set of guidelines for the diagnosis of celiac disease in 2012. If celiac disease was suspected based on history and physical, the provider was encouraged to draw a serum t TG and a total Immunoglobulin A (Ig A). If the t TG comes back negative, this patient is thought not to have celiac disease and other conditions should be explored. If the t TG comes back positive, the recommenda-tion is to transfer to a pediatric GI specialist, as celiac is a likely diagnosis (Husby et al., 2012). Other blood tests that help to guide the diagnosis include serum endomysial antibody (EMA) and HLA‐DQ2 and HLA‐DQ8, which are generally ordered by DNA testing and interpreted by gastroenterol-ogists (Husby et al., 2012). ESPGHAN notes that “HLA‐DQ2/HLA‐DQ8 typing has a role in the case finding strategy in individuals who belong to groups at risk for CD. A negative result for HLA‐DQ2/HLA‐DQ8 renders CD highly unlikely in these children, and hence there is no need for subsequent CD antibodies testing in such individuals” (Husby et al., 2012, p. 145). Those who have HLA‐DQ2/HLA‐DQ8 positivity should note that while its absence is sensitive to not having celiac disease, it is not specific for having celiac disease. In such a circumstance, results of blood tests previously noted, specifically the results of the EMA test (a positive test in addition to positive HLA testing would indi-cate celiac disease), a duodenal endoscopy, and a work‐up for other ailments should be taken into consideration before confirming a diagnosis of celiac disease (see Figure 4. 9. 1, Husby, 2012, p. 153). A duodenal endoscopy remains a gold standard in the diagnosis of celiac disease, albeit a controversial one. Because celiac disease typically is associated with “an incr eased number of intraepithelial lymphocytes (>25 per 100 enterocytes), elongation of the crypts, and partial to total villous atrophy” in the small intestine, biopsies have been recommended to both grade the severity of the disease (using the Marsh scale) and monitor for improvement over time (Leonard et al., 2017, p. 651). Recently, ESPGHAN has stated that a biopsy can be omitted if a patient has “signs and symptoms suggesting celiac disease, a positive anti‐t TG antibodies finding with a level greater Table 4. 9. 1. Classification of Symptoms. Category of Symptom Symptoms/Conditions Gastrointestinal Abdominal pain Diarrhea or Constipation Vomiting Nongastrointestinal Failure to thrive Loss of dental enamel Dermatitis herpetiformis Iron‐deficiency anemia Osteoporosis/ Osteopenia Common co‐occurring conditions Type 1 diabetes Thyroid conditions Down syndrome First‐degree relatives with celiac disease Family member with Multiple miscarriages Source: From Nahar et al. (2019) Sealing the Diagnosis of Celiac Disease in Pregnancy. The Medicine Forum: Vol. 20, Article 9.
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Gastrointestinal Complaint 353 than 10 times the upper limit of normal, a positive antiendomysial antibody finding obtained at a different time than the anti‐t TG antibodies finding, and a HLA genotype compatible with celiac disease” (Leonard et al., 2017, p. 651). It is no longer recommended to monitor improvement in diagnosis status or adherence to gluten‐free diet through serial endoscopies as villous changes may take long to heal, risk to the patient may outweigh the benefit, and simple blood tests provide ade-quate markers, usually at a lower costs and risks to patients. What other information gathered through noninvasive methods would help to confirm the diagnosis? A detailed history might be the most important aspect of diagnosing celiac disease. Specific ques-tions that a primary care provider might ask include: When did Katie begin expanding her food prefer ences? What types of foods did she enjoy before? What type of food does she prefer now? When did Katie first begin to have GI symptoms? Do the symptoms seem related to meals/ mealtime? Is it always diarrhea or are there other complaints? What is Katie's general stooling pattern (e. g., Does she stool daily? Does she have a history of constipation? Any history of blood in the stool?) Does Katie have a history of food allergy? Does anyone else in the house have a history of a food aller gy? What happens when that person ingests that food? Have you kept a food diary or tried to track symptoms to time of day, meals, schoolwork, and so on? If so, have you noticed any patterns? What is school like? Does Katie have friends? Participate in activities? Is she making good grades? Have teachers expressed any concerns? Does Katie take naps during the day? If so, for how long? How does she sleep at night?Anti-TG2 lg A & to tal lg A* Pos. Anti-TG2 >10 x normal EMA pos. HLA pos. EMA pos. HLA neg. EMA neg. HLA neg. EMA neg. HLA pos. Marsh 0-1 Marsh 2 or 3Pos. Anti-TG2 <10 x normal Anti-TG2 negative Anti-TG2 positive Not CD EMA & HLA DQ8/DQ2 OEGD & biopsies CD+ GFD & F/u CD+ GFD & F/u Transfer to Paediatric GI Paed GI discusses with fa mily the 2 diagonstic pathw ays and consequences considering patient's history & anti-TG2 liters Consider furt her diagnostic te sting if, Ig A deficiency Age <2 years History-low glut en inta ke-drug pretreatment-severe sympto ms-associated diseases Consider fa lse neg. HLA te st. Consider biopsies Consider fa lse pos. anti-TG2Consider false pos. serology false neg. biopsy or potential CD Extended ev aluation of HLA/serology/biopsies Unclear case Not av ailable Figure 4. 9. 1. Child/Adolescent with Symptoms Suggestive of Celiac Disease.
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354 Resolutions What other symptoms is Katie experiencing? What have you tried to make her symptoms better? Does anything help? Does anything make it worse? Review of her growth chart: Is ther e a true slowing of growth? When did it start? How severe is it? Is it only height that has slowed? Only weight? Both? Is there a family history of plateaued or diminished growth? Beyond a solid history, a careful clinical exam is also warranted. Special attention should be paid to the following: Evidence of dental enamel changes Pallor (suggestive of anemia) Evidence of malnutrition: examine hair, skin, nails Abdominal exam, as this is the greatest single source of discomfort. Take note of distention, localized pain, and hyper or decreased bowel sounds. Abnormal thyroid (celiac and thyr oid conditions are often co‐occurring conditions) If examining genitalia, look for delayed development via Tanner staging. Phenotypic evidence of genetic diseases such as Down syndrome, T urner syndrome, Williams syndrome, which have an association with CD. What information from the family history helps to guide your differentials? Family history is an important consideration in celiac disease. Those at greatest risk for celiac are those with first‐degree relatives with the disease. Outside of that group, ESPGHAN suggests that “Testing should be offered to . . . children and adolescents with the otherwise unexplained symp-toms and signs of chronic or intermittent diarrhea, failure to thrive, weight loss, stunted growth, delayed puberty, amenorrhea, iron‐deficiency anemia. . . ” as well as to patients with “type 1 diabetes mellitus, Down syndrome, autoimmune thyroid disease, Turner syndrome, Williams syn-drome, selective immunoglobulin A deficiency, autoimmune liver disease, and first‐degree rela-tives with CD” (Husby et al., 2012, p. 137). In our case, Katie does not have a first‐degree relative with celiac, although her mother could have asymptomatic disease given that her sister has it. It is also useful to consider any symptoms of Katie's siblings when assessing potential risk for celiac disease. Katie's mother's history of miscarriage is also common in celiac disease and may help to support the decision to test for the disease. There is disagreement within the medical community whether those without any symptoms, regardless of risk factors, should be screened. The U. S. Preventive Services Task Force recommends against this practice because of the risks associated with false positive results and the emotional strain that can come from testing. (U. S. Preventive Services Task Force, 2017). Alternatively, ESPGHAN has an algorithm dedicated to “the Child Without Symptoms Suggestive of CD Who Belongs to a High‐Risk Group” (Husby et al., 2012, p. 154). It is the opinion of this group that the potential damage to the body and the high risk of celiac is adequate rationale for pursuing confirmation testing. Once the diagnosis is established, what other multidisciplinary support would you offer the patient and family? What other medical specialties/subspecialties would you engage? Pediatric celiac disease is one that is best diagnosed and ultimately managed by a pediatric gas-troenterologist. The only available treatment for this disease is a lifelong, strict adherence to a gluten‐free diet. While many have dabbled in this diet, helping to elevate it to fad status, when it is being undertaken for medical reasons, it is a difficult and costly one to maintain. As a primary care provider, it should be stressed to patients and their families that a gluten‐free diet should not be initiated until a positive diagnosis has been made, as low levels of ingestion atypical to the patient's presenting diet during a work‐up may give false‐negative test results. When patients are diagnosed with celiac disease the following may be useful to provide both concurrent and sup-portive care within the primary care space:
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Nutrition: Register ed dieticians can provide guidance on a gluten‐free diet, teach patients and families how to read and interpret labels, and can help correct nutritional deficiencies (e. g., vitamin supplementation and/or electrolyte correction) that may have existed prior to the diag-nosis. Recent studies have demonstrated that gluten‐free diets are often high in carbohydrates and fat and lack micronutrients. A review of several diets demonstrate a near‐universal lack of folate (Mager et al., 2019). For patients with special considerations, including vegetarianism or food allergies, a registered dietician is an invaluable resource. Psychology/ Mental health: Children with celiac disease can experience an impaired quality of life due to their diet restrictions, uncomfortable symptoms, anxiety related to “tainted” food, and bullying related to their condition. Having a mental health provider who can normalize feelings and teach strategies to overcome stressors at different developmental milestones is an important aspect to holistic care. See, for example, Cadenhead et al. (2019) for more information on coping with a chronic illness. A provider who can expertly identify and address concerns related to eating disorders is also a welcome resource. There are associations between anorexia and celiac disease, which should be screened for and further researched. Having a knowledge-able resource to help with the complexity of a restricted diet due a chronic health condition and the psychological and deleterious effects of anorexia will benefit patients and family alike (Cadenhead et al., 2019; Marild et al., 2017). School nurses/Resources: Childr en with celiac disease that is suboptimially managed may experience greater school absences due to disease flairs and accidental gluten ingestion has a greater chance of happening outside of a more‐controlled home setting. As such, students—especially young ones—need to have a resource person at school whom they can disclose their symptoms to, create a plan for management of said symptoms (e. g., using the bathroom in the nurse's office), and coordinate missed work with teachers. Educating teachers about the effect of gluten ingestion and collaborating with the student to discreetly leave the room, if necessary, can help decrease the stigma and embarrassment of celiac disease. If patients have numerous hospitalizations or medical appointments, an IEP may be necessary to prevent the child from falling behind in school. As Katie ages, further discussion and emphasis on the importance of adherence to the gluten‐free diet and ownership of food choices will need to be had. Teenagers are at a high risk for poor diet compliance, which can result in a decreased quality of life due to worsening symptoms and social isolation. As Mager and colleagues write,. . . the major factors influencing adherence to the GFD [gluten free diet] included the presence of GI symptoms, age of the child, and ethnicity. This was particularly important to adoles-cents with CD where consideration of the school environment, thoughts of feeling different and social settings were drivers of reduced adherence to the GFD. (Mager et al., 2018, p. 947) Subspecialties: Beyond pediatric gastroenterologists, other subspecialists might be necessary based on other symptoms and co‐morbidities. For example, if a patient has a microcytic anemia, a referral to a hematologist might be warranted. If there is evidence suggestive of osteoporosis or osteopenia, a referral to an orthopedist might be appropriate. If there are concerns related to diabetes or thyroid conditions, endocrinology would also be a necessary service to engage. And finally, if there are reasons to suspect other genetic conditions, a referral to a genetic counselor should be considered to help understand underlying pathologies and their possible consequences. All of these recommendations, however, are made with the assumption that a large, pediatric hospital is accessible to the patient. If a pediatric facility is not available, the family may be required to travel long distances to access one or the primary care provider may be tasked with reviewing recommendations, seeking out consultations, and managing co‐morbidities for which they do not have specialized knowledge and training. This type of complex care requires a lot of time and energy of the primary care specialist but also deprives the patient of experts in pediatric subspecialties. As such, initial consultation by the patient and their families complete with an Gastrointestinal Complaint 355
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356 Resolutions individualized plan for treatment and follow‐up with a pediatric specialist is always preferable, even if long‐term management is not possible. Special considerations: People who are diagnosed with celiac disease face a life of gluten‐free eating. Failure to adhere to this diet can lead to clinical manifestations such as abdominal pain, bloating, diarrhea, and constipation. If severe, short‐term complications from these side effects can include dehydration, hypovolemic shock, and infection. Long‐term consequences include damage to the intestinal tract and villous, chronic inflammation; loss of bone mineral density, which increases the risk of fracture; damage to teeth; and chronic anemia, to name a few. As such, strict adherence to this diet is an imperative. However, socioeconomic and sociocultural realities must be faced and addressed (see, e. g., Mager, 2018; Mager, 2019). Discussing access to appropriate food, willingness to potentially change the patient's diet to include foods that are foreign or otherwise not eaten by the rest of family, affordability of food, and ability to attend multiple medical appointments and undergo numerous medical tests should all be considered when providing comprehensive care. Creating plans that are realistic and of maximum benefit to the patient must be made and establish-ing a partnership with families and subspecialists may also improve adherence. REFERENCES AND RESOURCES Cadenhead, J. W., Wold, R. L., Lebwohl, B., Lee, A. R., Zybert, P., Reilly, N. R., . . . Green, P. H. R. (2019). Diminished quality of life among adolescents with coeliac disease using maladaptive eating behaviours to manage a gluten‐free diet: A cross‐sectional, mixed‐methods study. Journal of Human Nutrition and Dietetics 32, 311-320. Fedewa, M. V., Bentley, J. L., Higgins, S., Kindler, J. M., Esco, M. R., & Mac Donald, H. V. (2019). Celiac disease and bone health in children and adolescents: A systematic review and meta‐analysis. Journal of Clinical Densitometry: Assessment and Management of Musculoskeletal Health (in press): 1-11. Husby, S., Koletzko, S., Korponay‐Szabo, I. R., Mearin, M. L., Phillips, A., Shamir, R., . . . Zimmer, K. P. for the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. (2012). European Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines for the diagnosis of coeliac disease. Journal of Pediatric Gastroenterology and Nutrition, 54(1), 136-160. Khatib, M., Baker, R. D., Ly, E. K., Kozielski, R., & Baker, S. (2016). Presenting pattern of pediatric celiac dis-ease. Journal of Pediatric Gastroenterology and Nutrition, 62, 60-63. Lebwohl, B., Sanders, D. S., & Green, P. H. R. (2018). Coeliac disease. Lancet, 391, 70-81. Leonard, M. M., Sapone, A., Catassi, C., & Fasano, A. (2017). Celiac disease and nonceliac gluten sensitivity: A review. Journal of the American Medical Association, 318(7), 647-656. Mager, D. R., Macron, M., Brill, H., Liu, A., Radmanovich, K., Mileski, H.,. . . Turner, J. M. (2018). Adherence to the gluten‐free diet and health‐related quality of life in an ethnically diverse pediatric population with celiac disease. Journal of Pediatric Gastroenterology and Nutrition, 66 (6), 941-948. Mager, D. R., Liu, A., Macron, M., Harms, K., Brill, H., Mileski, H., . . . Turner, J. M. (2019). Diet patterns in an ethnically diverse pediatric population with celiac disease and chronic gastrointestinal complaints. Clinical Nutrition ESPEN, 20, 73-80. Marild, K., Stordal, K., Bulik, C. M., Rewers, M., Ekbom, A., Liu, E., & Ludvigsson, J. F. (2017). Celiac disease and anorexia nervosa: A nationwide study. Pediatrics, 139(5), e20164367. Nahar, R., & Avani, A. (2019). Sealing the diagnosis of celiac disease in pregnancy. The Medicine Forum, 20(9). https://doi. org/10. 29046/TMF. 020. 1. 008; available at: https://jdc. jefferson. edu/tmf/vol20/iss1/9 North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. (2005). Guideline for the diagnosis and treatment of celiac disease in children: Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. https://www. naspghan. org/files/documents/pdfs/position‐papers/celiac_guideline_2004_jpgn. pdf U. S. Preventive Services Task Force. (2017). Screen for celiac disease: U. S. Preventive Services Task Force rec-ommendation statement. Journal of the American Medical Association, 317(12),1252-1257.
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357 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION What are the top three differential diagnoses? What testing will confirm the diagnosis? The differential diagnosis for this patient would include: celiac disease, food protein-induced enteropathy, food allergy, or food intolerance. Celiac disease typically presents with abdominal pain, diarrhea, and reflux (Khatib, Baker, Ly, Kozielski, & Baker, 2016). Some patients may experi-ence nongastrointestinal symptoms, but these do not include respiratory compromise or hives as a result of gluten ingestion. Thus, James's symptoms of hives and respiratory distress would suggest against celiac. Food protein-induced enteropathy is a non‐Ig E moderated food allergy most com-monly associated with milk protein intolerance (Nowak‐Wegrzyn, 2015). This condition usually presents in infancy and is relatively rare. Based on the type of foods that James was eating and his age, this also seems like a less likely diagnosis. That leaves food allergy and food intolerance on our list of differentials. Anaphylaxis is defined as An acute, severe, life‐threatening allergic reaction in presensitized individuals, leading to a systemic response caused by the release of immune and inflammatory mediators from baso-phils and mast cells. At least two organ systems are involved, such as the skin, the upper and lower airways, and the cardiovascular, neurologic, and gastrointestinal systems, in this order of priority or in combination. (Andreae & Andrea, 2019) Based on this definition, what James experienced was an anaphylactic reaction, which occurs only with allergy—not intolerance. Therefore, we can feel confident that James experienced an allergic reaction, most likely to something that he was eating. The next question is, what is James allergic to? James was eating a peanut butter and jelly sandwich, but there are a lot of details that are left out. For example, what type of jelly? What type of bread (e. g., nut bread? Whole wheat?)? What type of peanut butter—does it include any other type of nut? Time to reaction (while eating? Minutes‐to‐hours later)? What else was he eating or drinking at the time (another potential source of allergen)? These details of the history will help to guide the testing for the source of the allergen. The most common sources of food allergy are egg, milk, peanuts, soy, tree nuts, wheat, and shell-fish (Guandalini & Newland, 2011, p. 428). Willitis and colleagues note that the most common Case 4. 10 Food Allergies
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358 Resolutions childhood allergy in their study was the tree nut. This may help James's provider feel more con-fident in labeling peanut butter as the culprit for James's allergy (Willits et al., 2018, p. 1425). Peanut butter allergy: According to the National Institute for Allergy and Infectious Diseases, the gold standard for diagnosis of food allergy includes history; physical; skin prick test with associated skin and organ findings; allergen‐specific serum Ig E; and oral food challenge, which can be open label or blinded (Boyce, Assa'ad, & Burks, 2012, pp. 10-12). These methods of testing should be used in combination as opposed to singular approaches, as this gives the highest levels of specificity and sensitivity. It is the job of the pediatric primary care provider to give a referral to a qualified pediatric allergist who can supervise the testing and interpret the findings. Another piece of the history that the primary care provider should recognize as a possible con-nection to a food allergy is James's history of eczema. “It is well known that family history of atopy and atopic dermatitis are risk factors in the development of Ig E mediated food allergies with the coexistence of asthma being the most commonly identified factor for severe reactions” (Guandalini & Newland, 2011, p. 428). Performing a careful clinical exam to learn the extent of the skin changes and monitoring for worsening eczema will be important for the provider moving forward. In addition, reviewing past medical records and history with James's mother to look for indications of asthma, reactive airway disease, or other concerns with regard to the respiratory system may help to narrow the differential diagnoses. How should the provider educate the mother about the seriousness of anaphylaxis and the risk of it occurring again? James's mother is hopeful that her son does not have a true, anaphylactic allergy to peanuts. This is an understandable position; it can be overwhelming to care for children with severe allergies. Children and families must learn to read labels, carry emergency medications, and avoid triggers, and the patients are often the target of bullies in school (Feng & Kim, 2018). It is the role of the primary care provider to explain the life‐threatening nature of anaphylactic food allergies, provide resources and education related to the reading and interpretation of food labels, coordinate with school administration to create a safe environment, and help the family to create an appropriate home setting for the food‐allergic child. The primary care provider or their staff should take the time to review with the parents and patient the proper use and timing of single‐use, injectable epinephrine (usually an Epi Pen) and subsequent emergency management of anaphylaxis. On the flip side, parents will sometimes believe that their child has a food allergy when, in fact, they do not. “. . . self‐reported allergy typically overestimates true allergy.. . . In one meta‐analysis, the rate of self‐reported food allergy among children was 12%, compared with 3% when confirma-tory testing was performed (Sichereret al., 2017, p. 3). Parents and children will believe that signs of an intolerance, such as flatulence or gastrointestinal discomfort when consuming milk products, indicates an allergy requiring that specific foods be avoided and changes to the school and home setting must be made. Educating parents and caregivers about the specific symptom and treatment differences between intolerances and allergies is an important job for the primary care provider. This can provide ease of mind for those without allergies and bring greater awareness to the seri-ousness of Ig E mediated allergies. How can the provider help the school manage a child with food allergies? One role of the primary care provider is to be a public health advocate in their community. This can be accomplished through several means with regard to food allergies. For example, the American Academy of Pediatrics (AAP) recommends that physicians teach caregivers and teachers to: recognize the symptoms of anaphylaxis versus simple allergy and how to manage each; the proper use and timing of an Epi Pen or its equivalent; provide epinephrine prescriptions for schools to be used for unexpected reactions as local and state laws allow (i. e., not associated with any particular student); and provide families with known allergies a prescription that allows for a
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Food Allergies 359 supply of Epi Pens that cover both school and home settings” (Sicherer, Mahr, & Section on Allergy and Immunology, 2010). The AAP also provides templates for providers to use when completing allergy action plans to be used in school or similar settings that has simple instructions for what to do during an allergic and/or anaphylactic reaction (Wang, Sicherer, & Section on Allergy and Immunology, 2017). If this family does not have insurance, what is the expected out‐of‐pocket expense for an Epi Pen? Likely more than one will be needed, so how can a family navigate this barrier? The cost of injectable, single‐use epinephrine can be very high, even with prescription drug insur-ance coverage. In fact, there has been national press spotlighting both its cost and lack of avail-ability (see, e. g., Kaplan, 2018). Although there are now several options for single‐use injectable epinephrine, some require private insurance while others are hampered by lack of availability for the smaller doses. If access to medication proves to be a barrier for James and his family, the primary care provider has several options. First, they can attempt to procure samples directly from the drug company. While this seems like an obvious fix to a problem, in‐office drug samples are often not allowed due to ethical concerns with regard to the relationship between pharmaceutical companies and physi-cians. If this route is not an option for James's provider, they can next attempt to negotiate with pharmacies and/or insurance companies. While providers may not perform this task directly, case managers and nursing staff within the practice will need to take time and resources out of a clinic to perform this exercise. Ultimately, it may be the responsibility of the provider to conduct a peer‐to‐peer consultation with insurance to confirm the medical necessity of a product. A third option would be to provide vials of epinephrine along with a syringe that the family would be responsible for drawing up as needed. While this is very cost effective, it is also not ideal for most families, as the ability to think clearly and quickly draw up medication into a syringe in the setting of an emergency can be overwhelming for nonmedically trained parents. In addition, schools may not accept vials and syringes if there is no school nurse present, as the liability may be too great. What is the essential information that all caregivers (not just parents) need to know when caring for James? The most essential information is twofold: First, the only way to prevent an allergic reaction is to completely avoid the allergen. Reading labels, knowing what other nontraditional products may contain the allergen, and teaching the child to avoid the trigger is vital. The second piece of information is the swift recognition and treatment of an allergic reaction. Teaching caregivers the signs and symptoms of anaphylaxis and empowering them to use the epi-nephrine is the best way to help halt a reaction. “Researchers suggest that epinephrine is safe but often underutilized and that there is poor recognition about both how and when to use epinephrine autoinjectors” (Sicherer et al., 2017, p. 4). While no one wants to cause pain or suffering by giving a deep, intramuscular injection, the overall health, safety, and life of a child outweighs these risks. Adults must be willing to use the epinephrine and call emergency personnel for further management in the setting of anaphylactic reactions. The side effects of epinephrine, including tachycardia, nausea, and tremors, are all temporary and generally are not dangerous. Again, these side effects outweigh the anoxia and damage caused by lack of perfusion during an anaphylactic allergic reac-tion. As such, providers should consider using some of their time to teach caregivers the signs of anaphylaxis (see Table 4. 10. 1) as compared to simple allergy (see Table 4. 10. 2). Allowing caregivers the opportunity to use the epinephrine “trainer” (an Epi Pen without the needle or medication that can be used to practice the injection) to familiarize themselves with the setup and force needed to activate the pen can go a long way in fostering an environment that is supportive, educated, and empowered. Caregivers can also be taught to give antihistamines such as Benadryl or Zyrtec for simple hives or uncomplicated itching. It should be impressed upon caregivers that for patients who are prescribed emergency epinephrine, it must be carried on the person who has the allergy (or by
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360 Resolutions an accompanying responsible adult) at all times. Lack of epinephrine leads to delays in treatment that can result in fatal outcomes (Warren, Zaslavsky, Kan, Spergel, & Gupta, 2018). Normalizing the carrying of epinephrine and knowing when to use it will help the child feel empowered to partici-pate in activities with peers. The child with an allergy will also feel secure knowing that there is a plan and readily available medication should it be necessary, which might allow them to venture outside the confines of their allergen‐controlled environment. What advice should the mother be given regarding introduction of peanut‐based products to the youngest child now that food allergies are known to be in the family? Primary care providers should be able to anticipate that parents of a child with an allergy will also want to know about the risks of allergies to their other children. In a seminal study published in 2015, Du Toit and colleagues demonstrated that rather than delaying the introduction of peanuts in high‐risk populations, as had previously been recommended by the AAP, there is actually a protective factor in the early introduction of the potential allergen (Du Toit et al., 2015). The findings from the Learning Early About Peanut (LEAP) study warned, however, that these results were not generalizable to all types of food allergens. “The authors concluded that, in children at high risk for allergy, the early introduction of peanuts significantly decreased peanut allergy. Furthermore, authors pointed out that early consumption of peanut in high‐risk infants is allergen specific and does not prevent the development of other allergic disease” (Ferraro, Zanconato, & Carraro, 2019, p. 1131). Specifically, it should be noted that “there is no need to delay the introduction of aller-genic foods beyond 6 months of age and that they should not be introduced before 4 months of age” (Greer, Sicherer, Burks, & Committee on Nutrition, Section on Allergy and Immunology, 2019, p. 4). Indeed, with limited exception to the child at highest risk for allergy, no testing is necessary prior to administration. Primary care providers should take the time to review sibling risk factors, including the presence of eczema, allergies, and family history before making a recommendation to seek testing for siblings. Parents should be counseled about the risk of keeping known allergens in the house and the danger associated with giving “just a little peanut butter” to siblings or friends with severe allergies. Siblings can be taught how to recognize signs of anaphylaxis in their siblings with allergies. For mothers of newborns, “no conclusions can be made about the role of breastfeeding in either preventing or delaying the onset of specific food allergies” (Greer et al., 2019, p. 4). As such, it is generally advised that mothers continue to breastfeed as they had planned without modifications to diet or duration. Similarly, there has been speculation that the use of hydrolyzed formula would help prevent atopy and, possibly, later food allergy. “The overall results of these new studies have weakened previous conclusions that there was modest evidence that the use of either partially or Table 4. 10. 1. Symptoms of Anaphylaxis. Anaphylaxis Symptom Clinical Manifestations Respiratory ristress Wheezing, throat closing, bronchospasm Skin manifestations Diffuse hives, wheals Edema Periorbital or perioral edema Gastrointestinal distress Diarrhea, vomiting, severe abdominal cramping Table 4. 10. 2. Allergy Symptoms. Allergy Symptom Clinical Manifestation Itching Itching, with or without discrete hives Gastrointestinal changes Loose stools, cramping, flatulence
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extensively hydrolyzed formula prevents atopic dermatitis in high‐risk infants who are formula fed or initially breastfed after birth” (Greer et al., 2019, p. 4). Finally, there are advances being made in the treatment of food allergies. For families with access to pediatric allergists, desensitization through food oral immunotherapy can be an option. This is a process that must be closely supervised by an allergist, requires a significant amount of time, and comes with the risk of severe reactions during the process. “The objectives of this therapy is to have the patient become less sensitive to the allergen and to potentially eliminate adverse reactions to the food allergen” (Sitton & Temples, 2017, p. 101). Other potential treatments include sublingual immunotherapy, epicutaneous immunotherapy, food allergen modifications, and anti‐Ig E medications. To date, oral desensitization has been the most successful technique, but depend-ing on the goals and resources of families the other options may be beneficial. REFERENCES AND RESOURCES Andreae, D. A., & Andrea, M. H. (2019). Anaphylaxis. BMJ Best Practice. Last reviewed: June 2019. Available at: https://bestpractice. bmj. com/topics/en‐us/501 Boyce, J. A., Assa'ad, A., & Burks, A. W. (2012). Guidelines for the diagnosis and management of food allergy in the United States. Washington, DC: U. S. Department of Health and Human Services. Du Toit, G., Roberts, G., Sayre, P. H., Bahnson, H. T., Radulovic, S., Santos, A. F., . . . Lack, G. for the LEAP Study Team. (2015). Randomized trial of peanut consumption in infants at risk for peanut allergy. New England Journal of Medicine, 372(9), 803-813. Feng, C., & Kim, J. H. (2018). Beyond avoidance: The psychosocial impact of food allergies. Clinical Reviews of Allergy and Immunology. Published online September 1, 2018. Retrieved from: https://doi. org/10. 1007/s12016‐018‐8708‐x. Ferraro, V., Zanconato, S., & Carraro, S. (2019). Timing of food introduction and the risk of food allergies. Nutrients, 11, 1131. Greer, F. R., Sicherer, S. H., Burks, A. W., & Committee on Nutrition, Section on Allergy and Immunology. (2019). The effects of early nutritional interventions on the development of atopic disease in infants and children: The role of maternal dietary restriction, breastfeeding, hydrolyzed formulas, and timing of intro-duction of allergenic complementary foods. Pediatrics, 143(4), e20190281. Guandalini, S., & Newland, C. (2011). Differentiating food allergies from food intolerances. Current Gastroenterology Reports, 13(5), 426-434. Kaplan, S. (2018, August 16). FDA approves generic Epi Pen that may be cheaper. New York Times. https:// www. nytimes. com/2018/08/16/health/epipen‐generic‐drug‐prices. html Khatib, M., Baker, R. D., Ly, E. K., Kozielski, R., & Baker, S. S. (2016). Presenting pattern of pediatric celiac dis-ease. Journal of Pediatric Gastroenterology and Nutrition, 62(1), 60-63. Nowak‐Wegrzyn, A. (2015). Food protein‐induced enterocolitis syndrome. Allergy and Asthma Proceedings, 36(3), 172-184. Sicherer, S. H., Allen, K., Lack, G., Taylor, S. L., Donovan, S. M., & Oria, M. (2017). Critical issues in food allergy: A national consensus report. Pediatrics, 140(2), 3. Sicherer, S. H., Mahr, T., & Section on Allergy and Immunology. (2010). Clinical report—Management of food allergy in the school setting. Pediatrics, 126, 1232-1239. Sitton, C., Temples, H. S. (2017). Practice guidelines for peanut allergies. Journal of Pediatric Health Care, 32(1), 101. Wang, J., Sicherer, S. H., & Section on Allergy and Immunology. (2017). Guidance on completing a written allergy and anaphylaxis emergency plan. Pediatrics, 139(3), e20164005. https://pediatrics. aappublications. org/content/pediatrics/139/3/e20164005. full. pdf Warren, C. M., Zaslavsky, J. M., Kan, K., Spergel, J. M., & Gupta, R. S. (2018). Epinephrine auto‐injector carriage and use practices among US children, adolescents, and adults. Annals of Allergy, Asthma & Immunology, 121, 479-489. Willits, E. K., Park, M. A., Hartz, M. F., Schleck, C. D., Weaver, A. L., & Joshi, A. Y. (2018). Food allergy: A com-prehensive population‐based study. Mayo Clinic Proceedings, 93(10), 1425. Food Allergies 361
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363 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION Which diagnostic or imaging studies should be considered to assist with or con-firm the diagnosis? A lipid profile, oral glucose tolerance test, and insulin levels would provide a basis to determine if Tamika currently has risk factors for hypercholesterolemia, insulin resistance, or Type 2 diabetes. Sleep apnea should also be considered due to the history of snoring and its association with obe-sity. A sleep study should therefore be considered. BMI: Body mass index is a surrogate for adiposity. It is a number calculated from a person's weight in kilograms to their square height in meters. It provides an indicator of adiposity and is used to screen for weight categories that may lead to health problems. Oral glucose tolerance test (OGGT): This is a standard laboratory method to determine how the body metabolizes sugar. It is used to diagnose impaired glucose tolerance, a frequent precursor to type 2 diabetes. Insulin Resistance: Insulin, made in the pancreas, helps the body use glucose for energy. In insulin resistance, muscle, fat, and liver cells do not respond properly to insulin; and, as a result, the body requires more insulin to help glucose enter the cells. The pancreas eventually fails to keep up leading to elevated blood glucose levels and Type 2 diabetes. Cholesterol Screen: Cardiovascular disease risk factors are fairly common among obese children. These include elevated cholesterol levels, high blood pressure, and Type 2 diabetes. Sleep Study: Sleep apnea is a complication of obesity. It is associated with loud snoring and labored breathing. Psychosocial Evaluation: Psychosocial issues are a fairly common consequence of childhood obesity. Obese children are frequent targets of social discrimination and stigmatization. This can contribute to low self‐esteem that may hinder academic and social functioning over time. What is the most likely differential diagnosis and why? Exercise intolerance associated with obesity: The patient is a 12‐year‐old, Hispanic female with a primary complaint of shortness of breath with exertion. She denies any other symptoms and is taking no medications. Her physical exam is remarkable only for an elevated BMI of 34, which places her in the obese range at greater than the Case 4. 11 Obesity
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364 Resolutions 95th percentile for her age group, and darkly pigmented areas around her neck called acanthosis nigricans, a known risk factor for insulin resistance. Cardiovascular disease risk would be another major consideration in Tamika's health assessment. In addition to physical concerns, it is important for the provider to also monitor social and emotional development. Are any referrals needed at this time? Referral to a dietitian may be helpful. Referral to an ear, nose, and throat specialist would rule out any mechanical breathing difficulties due to enlarged tonsils or adenoids. Can the school be of assistance? A referral to the school nurse to counsel and support Tamika between office visits may be beneficial. What community resources are available to this family? Tamika would likely benefit from participation in an after‐school activity. Helping her to research programs at her school, her local Boys and Girls Clubs, or her YMCA may assist her on the way to a more active lifestyle. Use of Internet resources like Let's Move may provide ideas to find ways to be more active at home as well. What type of nutrition support may aid this family? Involving the entire family in discussing ways to improve eating habits and activity will likely pro-vide much needed guidance. Calorie and fat content lists from local fast‐food restaurants will offer guidance in making better food choices. REFERENCES AND RESOURCES Durbin, J. (2018). Pediatric obesity in primary practice: A review of the literature. Pediatric Nursing, 44, 202-206. Gaffney, K., Kitsantas, P., Brito, A., & Kastello, J. (2014). Baby steps in the prevention of childhood obesity: IOM guidelines for pediatric practice. Journal of Pediatric Nursing, 29, 108-113. Nelson, C., Colchamiro, R., Perkins, M., Taveras, E., Leung‐Strle, P., Kwass, J., & Woo Baidal, A. (2018). Racial/ ethnic differences in the effectiveness of a multisector childhood obesity prevention intervention. American Journal of Public Health, 108, 1200-1206. Reed, M., Cygan, H., Lui, K., & Mullen, M. (2016). Identification, prevention, and management of childhood overweight and obesity in a pediatric primary care center. Clinical Pediatrics, 55, 860-866. Santos, M., Cadieux, A., Gray, J., & Ward, W. (2016). Pediatric obesity in early childhood. Clinical Pediatrics, 55, 356-362. NOTE: The author would like to acknowledge Elaine Gustafson, MSN, PNP, who co‐authored this case in the first edition of this book.
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365 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 5. 1 Drug Use RESOLUTION What are the most likely differential diagnoses in this case and why? Substance use/abuse: While Natalie is not admitting to drug or frequent alcohol use, she does admit to social drinking and has been caught with marijuana and juuling. Her symptoms and behaviors as well as teacher reports indicate possible substance use and abuse. Major depressive disorder (MDD): Natalie is demonstrating several symptoms of MDD, including a loss of interest in activities and diminished ability to think or concentrate in class. She also presents with symptoms congruent with depression‐related problems including fatigue, difficulties feeling motivated and reduced functioning in grades over a period of months, and decreased school attendance and grades. Further assessment is needed to refine a diagnosis of MDD, and with Natalie refusing to complete standardized screening tools including the Patient History Questionnaire (PHQ) 9 and CRAFFT, the health care provider does not have full criteria for MDD at his time. However, depression should be of strong concern and is often comorbid with drug and alcohol use. School phobia: Refusal to go to school or school avoidance is a form of severe anxiety often referred to as “school phobia. ” School phobia is a chronic fear of attending school that interferes with normal life and can last weeks or more. Adolescents with school phobia often have trouble engaging in school, forming relationships or friendships, and are often correlated with being bullied in the school environment. While school phobia is more commonly reported in elementary school, high school students can also have severe school phobia. The health care provider should assess for possible bullying or life changes such as moving, parental divorce or conflict, or difficulty with peers. Academic difficulties or struggles should also be a concern at this point, especially in a 17‐year‐old who is near graduation. Students with school phobia often demonstrate physiological symptoms (vomiting, headaches, or gastrointestinal issues such as diarrhea). Students with school phobia can feel dizzy or cry uncontrollably at the possibility of having to attend school. While Natalie has been missing a considerable amount of school, she currently denies any of these symptoms. Natalie's pr esentation
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366 Resolutions is that she is showing little interest in doing well in school and would prefer to be doing other things: possibly marijuana and juuling, as indicated in her disciplinary reports from the school. Sleep problems: Natalie's fatigue is most likely related to drug and alcohol use with comorbid depression. Poor sleep hygiene is often common in adolescents and sleep problems are symptomatic for a variety of mental health disorders. It is important to obtain more information about sleep patterns and hygiene; however, this can be prioritized to a future visit. Thyroid disorder: When diagnosing depression, organic causes should also be considered in the differential. Hypothyroidism can cause depression, fatigue, weight gain, lack of energy, memory loss, and dif-ficulty processing information. What are the top diagnostic tests required in this case and why? Toxicology screen: Drug testing has been recommended in different clinical settings as a way to identify or avert drug use, or as part of treatment. However, there is very little consensus to date on indications for when to offer and require drug testing, as well as disagreement on how useful the results are. The common drug assays are urine, blood, breath, saliva, sweat, and hair. The cost, ease of collection, test type, time frame (results back and time since last use), as well as indications for testing, all vary wildly. Clinical practices and labs must be certified by the Clinical Laboratory Improvement Amendment (CLIA). Toxicology blood tests are the most useful for detecting drugs and alcohol but limitations include testing requirements within 2-12 hours of impairment and high cost, trained personnel, and equip-ment. Blood testing is rarely used in primary care settings; however, in high‐school SBHCs it is common for teachers, administration, and parents to request the provider to “run a toxicology screen” on a student. Beyond these limitations, the patient needs to consent for a toxicology screen of any kind, and the parent/guardian to additionally be involved in that conversation if the patient is under 18 years of age. Therefore, with Natalie's presentation and background at this visit, a toxicology screen is not one of the top diagnostic tests needed at this time. Thyroid panel: A blood panel that includes thyroid‐stimulating hormone (TSH), T3 and T4 hormone levels for specific indicators of a thyroid condition, can rule this out as a contributor to the Natalie's decreased mood. Natalie's presentation has changed from past years, and she does not regularly access care by a primary care provider who can track changes over time in development and pre-sentation; therefore, a thyroid blood panel should be considered. Suicide assessment: Treatment should include an immediate assessment for suicide risk. Natalie presents with enough indicators of depression that the provider should consider suicide ideation as a possibility. What are the concerns at this point? Natalie is presenting abnormally and with changes in behavior, demeanor, and attitude than in the past, including frequent visits to the SBHC, which include not wanting to be in school and signs for depression. She is describing sleep problems, which can compound mental health issues, and is at risk for early school dropout before graduation from her decline in academics. The physical examination revealed no obvious concerns for organic causes of depression or tiredness; however, Natalie is not followed by a primary care provider and utilizes emergency rooms and urgent care clinics for her care. Therefore, the provider should still consider a laboratory studies, including a thyroid panel, for a baseline and include a thorough physical assessment as part of her plan today.
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Drug Use 367 While Natalie is not admitting to drug use at this visit, she has a history of juuling in class and marijuana possession, both of which require further assessment and education on the risks of juul-ing and marijuana use. She has a past history of noncompliance with a low dose of an SSRI, Lexapro. While this isn't necessarily a concern at this point, it is important to note that Natalie was treated with pharmaceu-ticals for either depression, anxiety, or both in the past. What is the plan of treatment? The health care provider can utilize motivational interviewing techniques in order to elicit further response from Natalie or to engage in discussion about possible drug/alcohol use. Use open‐ended questions and if Natalie engages in conversation, ask for elaboration or more detail if she is willing to engage. Use affirming statements, when possible, commenting positively on her statements. Reflect on any change talk, for example, if she makes any statements indicating that she wishes her circumstances were different. The health care provider can ask about peer drug use and then try to engage in conversation on whether Natalie has tried the same substances. Be direct and nonjudg-mental in conversation. Do not force answers if Natalie does not engage in the conversation. If Natalie admits to further substance use, try to determine the frequency and amount and whether any adverse effects have previously occurred. What are the plans for referral and follow‐up care? Ask Natalie if she has ever been to a therapist for counseling and assess where, with whom, and for long, as well as her feelings about engaging in therapy. Asking about her previous experi-ence in therapy will help the referral process. Because Natalie is under the age of 18, reaching out to Natalie's parent or guardian on concerns for signs of depression and referral for counseling would be appropriate at this time. However, it is important to maintain Natalie's confidentiality at this point regarding anything specific she confides to the health care professional. Therapists are trained in further identifying substance use as a secondary diagnosis in mental health con-cerns and can further refer to a substance use counselor if indicated. At this point, we are not sure if Natalie is using frequently or engaging in social experimentation and exploration of substances. Follow‐up regarding Natalie's lack of sleep and fatigue are also beneficial to this case. Disrupted sleep is a symptom of many mental disorders but also can exacerbate mental disor-ders, including depression. Assess for inadequate levels of sleep including the quantity, quality, and satisfaction with sleep. Review sleep hygiene (caffeine consumption later in the day, bedtime routine, etc. ), as well as a sleep schedule. If sleep continues to be a concern, ask the patient to complete a sleep log (see an example at www. brightfutures. org/mentalhealth/pdf/families/ec/diary. pdf). What health education should be provided to this patient? Anticipatory guidance in a supportive manner should be given, including written handouts on either a specific substance or an overview of substance use. There are many recommended 1‐ page handouts for teens that can be found through the Drug Enforcement Agency (DEA), National Institute on Drug Abuse (NIDA), and National Institute of Alcohol Abuse and Alcoholism (NIAAA) websites. The majority of substance use begins in adolescence, when developing brains are most vulner-able. Early identification and treatment prevent long‐term consequences, such as academic diffi-culties and future mental health and substance use disorders. Many teens, and even adults, think marijuana is safe because it is now used medicinally and becoming decriminalized. Marijuana, whether smoked or vaped, can increase heart rate, make the veins in the eyes expand and look bloodshot, as well as affect coordination, driving, learning, and memory. The active ingredient, THC, affects the brain and causes dopamine release, which gives the feeling of a “high. ” However, this can also create feelings of worry, fear, and paranoia, and
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368 Resolutions cause delusions, hallucinations, and loss of senses. Studies have found that marijuana can make depression worse and some studies have found that heavy use of marijuana in youth can lead to schizophrenia for people who are already at risk and raise the risk of depression later in life. Because THC affects the brain's ability to make choices, teens who are using marijuana are also at risk for unsafe sex (and therefore HIV and STIs) or getting in the car with someone under the influence. Marijuana use and then withdrawal includes symptoms of irritability, not sleeping, not wanting to eat, anxiety, and craving more marijuana. Natalie asks, “Are you going to tell my mom about this?” How do you respond? Consult the local consent laws, as most states in the United States allow minor sto consent for care for alcohol and drug use. The health care provider should take this opportunity to discuss confi-dentiality with the patient, which includes needing to break confidentiality if the patient is: (1) at risk of harming themselves; (2) at risk of harming someone else; or (3) someone else harming them. Depending on how Natalie responded to the assessment for suicidality, the health care provider may decide to break confidentiality and reach out to the parent/guardian. Conversation with Natalie should include that you would like to refer her for counseling at this time, and parental consent will be needed. Reassure Natalie that nothing you've discussed so far will be shared with her mom, but that you need to let her mom know that you are concerned about signs of depression including chronic fatigue, struggling academics and engagement with peers, as well as loss of interest in things that she used to enjoy. Calling her mom with Natalie present and letting Natalie hear the conversation is another way to build trust with Natalie that specific details of their discussion are not shared but that concern for her mental health and well‐being is commu-nicated to her caregiver. Should Natalie's age be different, practitioners would additionally need to account for man-dated reporting laws for populations at risk (elderly or under age 13). Clinicians are to review the restrictions to confidentiality with the patient while engaged in risk assessments as described above and should also be familiar with the reporting laws in the state where they practice. Does the patient's psychosocial history impact how you might treat her? We know that Natalie has several risk factors, including living in a single‐parent household and having one sibling in prison and another who has unknown whereabouts. She admits to high‐risk behaviors, including sexual promiscuity and therefore engaging in discussion of STI testing and safe‐sex practices should also be considered. While we do know that Natalie lives at home with her mother, we do not know details about their relationship, her working status, or if any protective factors at home are present. Natalie's mom might work long hours or be absent in other ways since Natalie is now a teenager, which can also lead to patient feelings of abandonment. Gentle and nonjudgmental further assessment of her home life and social history can provide more details on how to best proceed. Finally, Natalie's medical history includes no history of depression, anxiety, or substance use disorder. However, we know that she was previously treated with an SSRI, which is used to treat depression and anxiety. Because Natalie does not utilize a primary care medical home for her care, this history may be difficult to untangle. Can minors seek substance abuse counseling without parental consent? The SBHC setting allows adolescents confidentiality for seeking certain health care services that are protected by law, such as reproductive care or substance abuse counseling and treatment. However, most adolescents still receive insurance benefits under their parent/guardian's insurance, and if said insurance is commercial insurance, an explanation of benefits (EOB) is sent home to the par-ent/guardian. Therefore, follow the agency or place of practice guidelines in billing for medical confidential visits. Some practices may have a grant or alternative billing options for patients who are under 18 years of age seeking this care, while some practices may write off these visits in order to assure confidentiality and that an EOB is not sent home.
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Drug Use 369 Are there any standardized guidelines that should be used to treat this case? If so, what are they? The Patient Health Questionnaire‐9 (PHQ‐9) and the Columbia-Suicide Severity Rating Scale (C‐ SSRS) are recommended for use in primary care to further screen for concerns related to depression and anxiety. These screening tools have been recommended by the American Academy of Pediatrics (AAP), the School‐Based Health Alliance, and the National Association of Pediatric Nurse Practitioners (NAPNAP) for routine use for screening students for mental health concerns. SBIRT (Screening, Brief Intervention, and Referral for Treatment) can clinically benefit youth, adolescents, and adults with mild to moderate substance use (not yet showing signs of dependence). SBIRT utilization has already been endorsed and recommended at the federal level by the Substance Abuse and Mental Health Services Administration (SAMHSA), the Veterans Administration (VA), the Department of Defense (Do D), the White House Office of National Drug Control Policies, dif-ferent managed care providers, and the School‐Based Health Alliance. SBIRT involves four different components for implementation, including: 1. Screening: Administer a validated screen tool recommended for adolescents (such as the S2BI or the CRAFFT) in order to identify youth who engage in substance use and may have pos-sible substance use disorders. It is recommended to also screen for depression and anxiety as they are comorbid with substance use (i. e., PHQ‐9, GAD‐7). 2. Brief intervention: The provider then engages a patient who scor es positive (above the screening tool threshold) in what is referred to as a “brief intervention” using motivational interviewing (MI) techniques and can range from a brief conversation to future counseling sessions. Discuss the advantages and disadvantages of substance use. Determine if substance use reduction or even abstinence is a goal of the patient and begin problem‐solving to reach that goal. 3. Referral to treatment: After screening and a brief intervention, the patient may still need a referral for treatment for either moderate or severe substance use or for depression and/or anxiety. MI can be used to accept the need for treatment and engage in counseling. Substance dependence may require referral for outpatient individual or group counseling for specialized substance abuse or even medically managed intensive treatment, which is often in‐patient. REFERENCES AND RESOURCES Adolescent SBIRT: Screening Brief Intervention & Referral to Treatment. (2019). At‐Risk in primary care: Adolescents: SBI with adolescents. Training available. https://kognito. com/products/sbi‐with‐adolescents. BNI‐Art Institute: Boston University School of Public Health. (2019). Adolescent Brief Negotiated Interview (BNI) algorithm. Retrieved from https://www. bu. edu/bniart/files/2011/10/Bilingual‐ADOLESCENT‐ ALGORITHM_3. 15. 11. pdf;http://www. ct. gov/dmhas/lib/dmhas/adpc/(7)_adolescent_sbirt. pdf Center for Adolescent Substance Use Research. (2018). The CRAFFT 2. 1 manual. http://crafft. org/wp‐ content/uploads/2018/08/FINAL‐CRAFFT‐2. 1_provider_manual_with‐CRAFFTN_2018‐04‐23. pdf Curtis B. L., Mc Lellan, A. T., & Gabellini, B. N. (2014). Translating SBIRT to public school settings: An initial test of feasibility. Journal of Substance Abuse Treatment, 46, 15-21. Kroenke, K., Spitzer R. L., & Williams, J. B. (2001). The PHQ‐9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613. Levy, S., Weiss, R., Sherritt, L., Ziemnik, R., Spalding, A., Van Hook, S., & Shrier, L. A. (2014). An electronic screen for triaging adolescent substance use by risk levels. JAMA Pediatrics, 168(9), 822-828. doi:10. 1001/ jamapediatrics. 2014. 774 Maslowsky, J., Capell, J. W., Moberg, D. P., & Brown, R. L. (2017). Universal school‐based implementation of screening, brief intervention and referral to treatment to reduce and prevent alcohol, marijuana, tobacco, and other drug use: Process and feasibility. Substance Abuse: Research and Treatment,11, 1-10.
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370 Resolutions Mitchell, S. G., Gryczynski, J., O'Grady, K. E., & Schwartz, R. P. (2013). SBIRT for adolescent drug and alcohol use: Current status and future directions. Journal of Substance Abuse Treatment, 44(5), 463-472. National Center for Mental Health Checkups at Columbia University. (n. d. ). PHQ‐9 modified for teens. Incorporating Mental Health Screening into Adolescent Office Visits. https://mmcp. health. maryland. gov/ epsdt/healthykids/Appendix Section4/PHQ‐9%20Modified. pdf Oregon Health and Science University. (2019) SBIRT Oregon: Clinic tools. http://www. sbirtoregon. org/ clinic‐tools/ Paschall, M. J., & Bersamin, M. (2018). School‐based mental health services, suicide risk and substance use among at‐risk adolescents in Oregon. Preventive Medicine,106, 209-215. Quanbeck, A., Lang, K., Enami, K., & Brown, R. (2010). A cost‐benefit analysis of Wisconsin's screening, brief intervention, and referral to treatment program: Adding the employer's perspective. WMJ, 109(1), 9-14. Tanner‐Smith, E. E., & Lipsey, M. W. (2015). Brief alcohol interventions for adolescents and young adults: A systematic review and meta‐analysis. Journal of Substance Abuse Treatment, 51, 1-18. doi:10. 1016/j. jsat. 2014. 09. 001
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371 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION What are the top differential diagnoses in this case and why? Eating disorder: An eating disorder is defined by an unhealthy attitude toward food that involves eating too much or too little, or becoming obsessed with weight and body shape. Symptoms of eating disorders including avoiding socialization when food is involved, eating very little food, making oneself sick after eating, constant worrying about weight and body shape, exercising too much, and/or very strict habits or routines around food. The most common eating disorders are: 1. Anorexia nervosa, which is defined by keeping weight as low as possible by not eating enough food, exercising too much, or both. 2. Bulimia nervosa, which is defined by loss of contr ol and eating a large amount of food in a short amount of time (binging) and then deliberately making oneself sick such as using a laxative, making oneself throw up, or overexercising to keep from gaining weight. 3. Binge‐eating disorder, in which the individual loses contr ol of eating and eats large portions of food to the point of feeling uncomfortable, upset, guilty, or sick. 4. Other specified feeding or eating disorder is when an individual does not meet the exact symptoms of anor exia, bulimia, or binge‐eating disorder. At this point, we know that Roseanne's mother is concerned about her weight but we do not know if Roseanne is concerned or is just strongly influenced by her mother or even her coach. She is a Division I athlete and is on a strict and constant exercise regimen. At this point she has a low BMI and does not get her periods (which can also be attributed to her birth control), which are symptoms of an eating disorder. Other physical symptoms are constantly feeling cold, tired, or dizzy and problems with digestion, all of which she denies. Excessive exercise: Compulsive exercise is common in athletes; compulsive exercisers are also sometimes referred to as “exercise addicts” or “obligatory athletes. ” High‐performance runners, professional athletes, and body builders are all reported to have exercise addiction. Excessive exercise can lead to injuries, Case 5. 2 Weight Loss
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372 Resolutions exhaustion, depression, and even suicide. Excessive exercisers will organize their lives around the exercise routine. At this time, excessive exercise is a concern, including the history of injuries from cheerleading. Malnutrition: Malnutrition occurs from an inadequate diet or problems absorbing nutrients from food. The most common causes of malnutrition are long‐term health conditions, low income, or a restricted diet. Unintentional weight loss (losing 5-10% of one's body weight over 3-6 months) is the most common symptom of malnutrition. Signs of malnutrition include weak muscles, chronic fatigue, low mood, frequent infections, or illnesses. An indicator of possible or high risk of malnutrition is a BMI under 18. 5, which means Roseanne is a candidate. Malabsorption: Causes of malabsorption are cystic fibrosis (or diseases that affect the pancreas), lactose intoler-ance, or intestinal disorders (such as celiac disease). Symptoms include abdominal discomfort (gas and bloating), frequent diarrhea, loose stool or stools that are light in color or bulky, weight loss, and frequent skin rashes. Roseanne's review of symptoms and physical examination makes malab-sorption less of a concern. Thyroid disorder: Hyperthyroidism from an overactive thyroid can cause unintentional weight loss (when appetite and food intake is the same or increased but the individual continues to lose weight), tachycardia, arrhyth-mias, heart palpitations, increased appetite, nervousness, anxiety, irritability, hand or finger tremors, sweating, changes in menstrual patterns, heat sensitivity, changes in bowel patterns, enlarged thy-roid goiter), fatigue, muscle weakness, difficulty sleeping, skin thinning, and fine, brittle hair. While we know Roseanne is excessively exercising and has abnormal menstrual patterns that are most likely from her frequent exercise, it is important to consider thyroid health at this point as well. Anxiety: Some adolescents have high standards and personal goals with disciplined behavior that can lead to anxiety surrounding control and perfectionism. However, when these behaviors interfere with social, emotional, and occupational functioning (including school performance or pressure) they can lead to an anxiety disorder. The most common somatic symptoms of pediatric anxiety disor-ders include restlessness, feeling sick to stomach, blushing, palpitations, muscle tension, sweating, trembling and shaking, easily fatigued, feeling paralyzed, chills, and hot flashes. At this time, neither Roseanne nor her mother is stating that any of these symptoms are a concern or pr oblem. Female athlete triad: Female athlete triad is a medical condition in physically active females involving: (1) low energy, with or without disordered eating; (2) menstrual dysfunction (usually amenorrhea); and (3) osteo-porosis. Long‐term consequences may not be reversible, making prevention, early diagnosis, and intervention important. Tracking menstruation is often useful for identifying athletes at risk and should be part of the preparticipatory sports physical. At this point, female athlete triad is a concern and one of the most likely primary diagnoses. What are the diagnostic tests required in this case and why? Laboratory evaluation of the amenorrheic athlete includes a pregnancy test, follicle‐stimulating hormone, thyroid‐stimulating hormone, and prolactin levels. Estradiol levels may also be helpful. Roseanne is currently on a birth control pill where she does not get her period, which is often preferred for female teenage athletes. However, even though she is on birth control, other causes of secondary amenorrhea should still be considered, including weight changes, pregnancy, stress, hypothyroidism, and prolactinoma. If Roseanne is sexually active, screening for sexually trans-mitted infections should also be included.
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Weight Loss 373 What are the concerns at this point? Concern about her weight is the main priority at this time, as Roseanne has a low body mass index and is a competitive athlete. She also has a history of broken bones requiring surgery, and while she is a competitive athlete in which these injuries are likely, early osteoporosis and her bone mineral density are a concern. Further exploration around when weight first became a concern and what her weight was a year ago at her last physical would be helpful. A full diet history of what Roseanne eats including how many calories she consumes should also be explored. As seen in female athlete triad, hypothalamic amenorrhea may result from the decrease in estrogen levels, which has a negative effect on bone density. Estrogen is involved in osteoclast and osteoblast activity, bone formation and resorption, and inhibits bone turnover. Adolescence is a time of peak bone mass accrual and therefore, this effect of estrogen during this developmental period is critical. Helping Roseanne, her mother, and possibly her coaches understand the long‐term effects on low bone density is important. A systemic review of randomized control trails and cohort studies show that bone loss reduction can be addressed through oral contraceptive pills (OCPs), which Roseanne is already taking. OCPs with 20-35 micrograms of ethinyl estradiol may help maintain bone mineral density. However, only the restoration of spontaneous menses through restoring energy balance offers best reversal of low bone mineral density concerns. Roseanne's mental well being is also a concern, including a lack of regular sleep (less than 8 hours on average) as well as the stress and pressure of maintaining a 4. 0 grade average and com-peting in a rigorous exercise schedule of being a Division I athlete. The provider can administer a standardized screening instrument for depression and anxiety (such as the PHQ‐9 or the SCARED) to help elicit further conversation around Roseanne's mental health. Should Roseanne's mother be asked to leave the room at this time? Why or why not? Roseanne's mother should be asked to leave the room so that you can ask and gather further information from Roseanne that she may not feel comfortable discussing in front of her mother. Confidentiality should be reviewed/explained to Roseanne. Areas that should be further explored include: Sexual activity: The provider should ask Roseanne about her current or past sexual activity including contraceptives beyond the birth control pill. Depending on her answers, health educa-tion surrounding STIs and HIV including possible testing and treatment should be explored. Social pressure: It would also be helpful to ask Roseanne about her competitive cheerlead-ing. Use open‐ended, nonconfrontational questions such as “Can you tell me more about your cheerleading?” Ask if she enjoys cheerleading without her mother present and further explore if she has a choice in her full schedule and constant practice. Try to elicit discussion on Roseanne's need for perfection and competitive nature. Ask what other activities she enjoys or participates in. Weight: While Roseanne's mother is concerned about her weight, ask Roseanne if she is concerned as well without her mother present. Inquire about her family and family dynamics bet-ween herself and her mom and dad. Ask if she snacks throughout the day and if she ever vomits after eating or takes laxatives or other diet pills or supplements. Ask if she ever eats in private when no one else is around or feels ashamed in eating or gaining weight. What is the plan of treatment? Long‐term risks for the female athlete triad include osteoporosis (and fracture), psychological effects of disordered eating, and eventually diminished athletic performance. Balancing energy availability, bone health, and menstrual function are indicators of a healthy athlete. The goal of treatment for the female athlete triad is adjusting energy expenditure and energy availability. Family‐based therapy and cognitive behavioral therapy are both effective for disordered eating.
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374 Resolutions Recommending a nutritionist (or a sports nutritionist) can help Roseanne (and her mother) deter-mine the quantity and quality of foods consumed as well as dietary supplementation. Daily intake of 1000-1300 mg of calcium and 600 units of Vitamin D is recommended. What are the plans for referral and follow‐up care? Depending on Roseanne's answers, further assessment may be necessary. The provider should assess the parotid gland, tooth enamel erosion, the palms for carotenemia, skin fold thickness and mid‐upper arm circumference, or the presence of Russell sign (calluses on the knuckles or back of hand due to repeated self‐induced vomiting over long periods of time). Roseanne's weight and eating patterns should be closely monitored in future visits and continued conversation should occur after her laboratory results come back. The female athlete triad takes a team approach and involving the sports nutritionist, coaches, parents, and a mental health care provider, if indicated, is critical. What health education should be provided to this patient? Discuss Roseanne's weight with both Roseanne and her mother. Emphasize that her body mass index is in the 6th percentile for weight and that this is low for her height and age. While her physical examination was normal, recommend that laboratory tests be ordered today and that no other medical problems exist. Provide education on nutrition, including maximizing bone density during adolescence and the importance of calcium and vitamin D supplementation. A food diary or journal can be suggested for recording weight, diet, and exercise. Long‐term consequences of osteoporosis and bone health are often not reversible. Dancers, gymnasts, and runners are usually at the highest risk of the triad and for long‐term effects and consequences. Often the low energy availability from restrictive eating of athletes is related to lack of proper nutrition knowledge as well as not making time to eat adequately. What demographic characteristics might affect this case? Certain regions of the country have what is sometimes referred to as extreme athletics at the secondary school level where youth and adolescents compete in rigorous sportsmanship in middle and high school (such as cheerleading, football, and bull riding in the Southern states). Are there any standardized guidelines that should be used to treat this case? If so, what are they? The American College of Obstetricians and Gynecologists (2017) have published recommendations for screening the female athletes triad, which include the following: 1. Do you worry about your weight or body composition? 2. Do you limit or carefully contr ol the foods that you eat? 3. Do you try to lose weight to meet weight or image/appearance requir ement in your sport? 4. Does your weight affect the way you feel about yourself? 5. Do you worry that you have lost control over how much you eat? 6. Do you make yourself vomit or use diuretics or laxatives after you eat? 7. Do you currently or have you ever suf fered from an eating disorder? 8. Do you ever eat in secret? 9. What age was your first menstrual period? 10. Do you have monthly menstrual cycles? 1 1. How many menstrual cycles have you had in your last year? 12. Have you ever had a stress factor? Sour ce: From Weiss Kelly, A. K., Hect, S., & Council on Sports Medicine and Fitness. (2016). The female athlete triad. Pediatrics, 138, 10. 1542/peds. 2016. 0922.
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Weight Loss 375 If this patient was male (instead of female), how would that change management and/or treatment? The International Olympic Committee has proposed changing the name to relative energy defi-ciency in sports (RED‐S) since males can also be affected. RED‐S also encompasses endocrine, met-abolic, hematologic, growth and development, cardiovascular, gastrointestinal, and immunological effects of energy deficiencies. REFERENCES AND RESOURCES American College of Obstetricians and Gynecologists. (2017). Committee Opinion No. 702. Female athlete triad. Obstetrics & Gynecology, 129, 3160-3167. American College of Obstetricians and Gynecologists. (2015). Committee Opinion No. 651. Menstruation in girls and adolescents: Using the menstrual cycle as a vital sign. Obstetrics & Gynecology, 126, e143-146. Bennell, K., White, S., & Crossley, K. (1999). The oral contraceptive pill: A revolution for sportswomen? British Journal Sports Medicine, 33, 321-328. Campbell, K., & Peebles, R. (2014). Eating disorders in children and adolescents: State of the art review. Pediatrics, 134, 582-592. Nazem, T. G., & Ackerman K. E. (2012). The female athlete triad. Sports Health, 4, 302-311. Weiss Kelly, A. K., Hecht, S., & Council on Sports Medicine and Fitness. (2016). The female athlete triad. Pediatrics, 138, 10. 1542/peds. 2016. 0922.
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377 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION What is the most likely differential diagnosis and why? Primary dysmenorrhea: Primary dysmenorrhea is defined as painful menstruation in the absence of pelvic pathology (American College of Obstetricians and Gynecologists [ACOG], 2015). Khaleesi is within the age range (14-18 years old) where symptoms of primary dysmenorrhea are most prevalent (Osayande & Mehulic, 2014). Diagnosis is often based on clinical history; Khaleesi's history of lower abdominal pain and cramps is consistent with the timing of the menstrual cycle. Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? Although Khaleesi denies sexual activity, it would be prudent to do a urine pregnancy test to rule out pregnancy, missed or threatened abortion, and offer tests for sexually transmitted infection (STI) screening. She also should have a CBC with differential checked with the history of frequent periods and therefore risk for anemia. In the absence of symptoms of STIs, a pelvic exam is not necessary (Bowers, 2018). What questions would you ask Khaleesi about her menstrual cycle? What was her age at menarche? During the first 1-2 years following menarche, cycles are highly irr egular and anovulatory. Once ovulation starts to occur, the amount of prostaglandin respon-sible for the symptoms associated with primary dysmenorrhea increases (ACOG, 2018; Bowers, 2018; Moriarty Daley & Fender, 2011). What are her number of days of bleeding and the number of hygienic pr oducts used in 24 hours? Consider a workup for bleeding disorders or secondary causes if: Bleeding lasts more than 7 days. Bleeding soaks through one or mor e tampons or pads every hour for several hours in a row. Patient will wear more than one pad at a time to contr ol menstrual flow. Patient needs to change pads or tampons during the night. Patient reports passing blood clots that ar e as big as a quarter or larger (ACOG, 2016). Case 5. 3 Menstrual Cramps
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378 Resolutions Ask her to describe her symptoms. Complaints of lower abdominal, back, and/or thigh pain at the onset of menstr uation is commonly reported with primary dysmenorrhea. Associated symptoms may also include nausea, vomiting, diarrhea, fatigue, and headache (Barassi et al., 2018; Osayande & Mehulic, 2014). If breast tenderness or bloating is reported, also consider a diag-nosis of premenstrual syndrome (PMS). Ask Khaleesi when she experiences the onset of pain. Symptoms of primary dysmenorr hea usually peak in the first 48 hours of menstrual flow, associated with the highest level of prostaglandins. Consider PMS if Khaleesi reports symptoms of pain and discomfort in the luteal phase: days 14 through 28 of the menstrual cycle. What additional information/questions are needed? Ask Khaleesi how often she participates in sexual activity and whether it is with males, females, or both. Ask whether she uses condoms 100% of the time. Obtain more detailed information about sexual activity to help to determine the risks of sexually transmitted infections (STIs) and pregnancy. Review signs and symptoms of STIs or pelvic inflammatory disease (PID) such as fever, abnormal vaginal discharge, or pelvic pain (Osayande & Mehulic, 2014). Ask Khaleesi if she has tried anything for her cramps. If a patient is alr eady using nonsteroidal anti‐inflammatory drugs (NSAIDs) or oral contraceptive pills (OCPs) without relief of symp-toms, consider an underlying pathology with a diagnosis of secondary dysmenorrhea (Barassi et al., 2018). Has she always had cramps or is this a more r ecent change? If an adolescent presents with menstrual pain before the age of 14 or first experiences menstrual pain after the age of 19, consider causes of secondary dysmenorrhea (Moriarty Daley & Fender, 2011). Is there a family history of endometriosis? Endometriosis is the most common cause of secondary dysmenorrhea, and should be considered with a history of menorrhagia, intermenstrual bleeding, dyspareunia, pain that occurs mid‐cycle or is acyclic, post‐coital bleeding, or infer-tility (Bowers, 2018; Osayande & Mehulic, 2014). Endometriosis in a first‐degree relative, or relatives with more severe disease, would warrant early screening for endometriosis (Bowers, 2018; Zannoni et al., 2014). Does she have a history of diarrhea, constipation, generalized abdominal pain, or passing gas? Information can help r ule out gastrointestinal disorders such as irritable bowel syndrome, lactose intolerance, constipation, and inflammatory bowel disease (Moriarty Daley & Fender, 2011). Does she have a history of psychosocial problems? A positive history of cigarette smoking, trauma, abuse, anxiety, depression, or other somatic complaints has been associated with symptoms of dysmenorrhea (ACOG, 2015; Moriarty Daley & Fender, 2011). What is the plan of treatment? NSAID therapy is the first‐line empiric treatment to disrupt cyclooxygenase‐mediated prosta-glandin production (ACOG, 2015; Bowers, 2018). Treatment can be started before menstruation, with the onset of symptoms, or with the beginning of menstruation. Ideally, medications should be taken 1-2 days prior to the anticipated onset of menses, and continued on a fixed schedule for 2-3 days (ACOG, 2015; Barassi et al., 2018; Bowers, 2018; Osayande & Mehulic, 2014). Ensure that the patient is taking an adequate dose, as subtherapeutic treatment is sometimes reported (Bowers, 2018). Taking NSAIDS with food and increasing fluid intake may help with GI and renal adverse affects (ACOG, 2015). NSAID treatment demonstrates effectiveness confirmed over placebo of all NSAIDs tested in a 2015 Cochrane Review (ACOG, 2015; Marjoribanks, Ayeleke, Farquhar, & Proctor, 2015). When NSAIDs were compared with each other, most studies found no evidence of a difference bet-ween them. See Table 5. 4. 1 for dosing and schedule of commonly prescribed NSAIDs for dysmenorrhea.
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Menstrual Cramps 379 After starting a specific NSAID, wait 2-3 cycles before switching medications if symptoms are not alleviated. Failure of NSAID treatments should not be determined unless they have been tried for longer than 3-6 months (ACOG 2015; Moriarty Daley & Fender, 2011). In addition to the use of NSAIDs, ACOG (2015) recommends hormonal contraception as an adjunct to NSAIDs to inhibit ovulation, thereby reducing prostaglandin release. Contraceptive counseling should be provided and decisions should be patient driven (ACOG, 2015; Bowers, 2018). Once started, the contraceptive method should be used for 3-4 months before considering treatment failure. Are there other options? Approximately 10-25% of patients do not respond to NSAID and hormonal contraception therapy. Limited evidence‐based research exists for alternative therapies (Barassi et al., 2018; Osayande & Mehulic, 2014). With low risk of harm and low cost of topical heat therapy and exercise, and the overall health benefits of exercise, ACOG (2015) encourages these two alternative options. Other examples of therapies include transcutaneous electric nerve stimulation (TENS), smoking cessation (ACOG, 2015), and acupuncture (Zhang et al., 2018). Neuromuscular therapy may ensure longer duration of NSAID analgesia (Barassi et al., 2018), and laparoscopic presacral neurectomy, and transdermal nitroglycerin have also been researched as alternative therapies (Moriarty Daley & Fender, 2011). Dietary modification and/or Supplementation with potential dietary supplements, include: Omega‐3 fatty acids, Thiamine (vitamin B 1), magnesium, fenu-greek, ginger, valerian, zataria, zinc, vitamin D. Safety and efficacy on herbal treatments is limited (ACOG, 2015). In treatment failure, consider secondary causes of dysmenorrhea including endometriosis, adenomyoisis, myomas, congential malformations, obstructions, or ovarian cysts (Bowers, 2018). Testing may include a bimanual gynecologic exam, and/or a transvaginal or abdominal ultrasound (Bowers, 2018). Diagnostic laparoscopy may be performed in cases with a high index of suspicion of endometriosis not confirmed by imaging or severe pain nonresponsive to therapies (Zannoni et al., 2014). Is it common for teen girls to miss school because of their periods? Yes. Dysmenorrhea is the number‐one reason for school absences and for refusal to participate in physical activity for adolescent females (Moriarty Daley & Fender, 2011). Adolescents who report severe dysmenorrhea show significantly higher absenteeism from school (Zannoni et al., 2014). It is also associated with a high rate of absenteeism from work (Barassi et al., 2018). When should she be seen for follow‐up? Patients should be monitored for response to treatment; consider following up in 8 weeks and as needed. A menstrual diary to include descriptions of pain, medication used and its effect, and any other symptoms will be helpful in determining treatment plan (Moriarty Daley & Fender, 2011). Table 5. 4. 1. Nonsteroidal Anti‐Inflammatory Drugs Used in the T reatment of Primary Dysmenorrhea. Drug Dosage Follow‐Up Dosing Celecoxib (Celebrex) For females older than 18400 mg initially 200 mg every 12 hours Ibuprofen(Advil, Motrin)200 to 600 mg every 6 hours Alternative: 800 mg initially200 to 600 mg every 6 hours Alternative: 800 mg every 8 hours Mefenamic acid 500 mg initially 250 mg every 6 hours Naproxen 440 to 550 mg initially 220 to 275 mg every 12 hours Source: Marjoribanks, J., Ayeleke, R. O., Farquhar, C., & Proctor, M. (2015). Nonsteroidal anti‐inflammatory drugs for dysmenorrhoea. Cochrane Database of Systematic Reviews, 2015(7), CD001751. doi:10. 1002/14651858. CD001751. pub3 (ACOG, 2015; Osayande & Mehulic, 2014).
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380 Resolutions Follow‐up appointments after initiating contraception should include review of pain symptoms, response to medications, and reviewing signs and symptoms for adverse affects of hormonal con-traception, or any concerns with use or adherence to use (Steenland, Zapata, Brahmi, Marchbanks, & Curtis, 2013). Blood pressure, weight, and warning signs for thromboembolism (using the mne-monic ACHES: abdominal pain, chest pain, headaches, eye problems, severe calf or thigh pain) should also be monitored at follow‐up visits. What health education should be provided to this patient? The American College of Obstetricians and Gynecologists (ACOG; 2015) regularly update patient information and handouts in both English and Spanish. Available at https://www. acog. org/Patients/FAQs/Dysmenorrhea‐Painful‐Periods Are there technologies available to assist this patient in her care? In addition to ACOG's website, there are many online resources available for adolescents to learn more about their menstrual cycle and symptoms. One valuable resource is kidshealth. org (Nemours Foundation, 2019), which includes audio explanations of periods, cramps, abnormal period,s and more topics, provided in both English and Spanish. The advent of apps in healthcare is also a useable resource for teens with smartphones. Popular period tracker apps including Period Tracker, Flo, Glow, Ovia, and Clue. Awareness of data collection through apps should be expr essed to adolescents (Kresge, Khrennikov, & Ramli, 2019), with emphasis on privacy settings. REFERENCES AND RESOURCES American College of Obstetricians and Gynecologists (2015, January). Dysmennorrhea: Painful period. https:// www. acog. org/Patients/FAQs/Dysmenorrhea‐Painful‐Periods American College of Obstetricians and Gynecologists (2016, June). Heavy menstrual bleeding. https://www. acog. org/Patients/FAQs/Heavy‐Menstrual‐Bleeding? American College of Obstetricians and Gynecologists (2018, December). Dysmenorrhea and endometriosis in the adolescent. https://www. acog. org/clinical/clinical‐guidance/committee‐opinion/articles/2018/12/ dysmenorrhea‐and‐endometriosis‐in‐the‐adolescent Bowers, R. (2018). Help teens and young women manage dysmenorrhea symptoms effectively. Contraceptive Technology Update, 40(2). www. reliasmedia. com/articles/143817 Barassi, G., Bellomo, R. G., Porreca, A., Di Felice, P. A., Prosperi, L., & Saggini, R. (2018). Somato‐visceral effects in the treatment of dysmenorrhea: Neuromuscular manual therapy and standard pharmacological treatment. Journal of Alternative & Complementary Medicine, 24(3), 291-299. doi:10. 1089/acm. 2017. 0182 Harel, Z. (2012). Dysmenorrhea in adolescents and young adults: An update on pharmacological treatments and management strategies. Expert Opinion on Pharmacotherapy, 13(15), 2157-2170. doi:10. 1517/14656566. 2 012. 725045 Kresge, N., Khrennikov, I., & Ramli, D. (2019, January 24). Period‐Tracking apps are monetizing women's extremely personal data: More than 100 million women monitor their cycles on their phones. Here come the ads. Bloomberg Businessweek. https://www. bloomberg. com/news/articles/2019‐01‐24/how‐period‐tracking‐ apps‐are‐monetizing‐women‐s‐extremely‐personal‐data Lauretti, G. R., Oliveira, R., Parada, F., & Mattos, A. L. (2015). The new portable transcutaneous electrical nerve stimulation device was efficacious in the control of primary dysmenorrhea cramp pain. Neuromodulation: Journal of the International Neuromodulation Society, 18(6), 522-526. https://doi‐org. 10. 1111/ner. 12269 Marjoribanks, J., Ayeleke, R. O., Farquhar, C., & Proctor, M. (2015). Nonsteroidal anti‐inflammatory drugs for dysmenorrhoea. Cochrane Database of Systematic Reviews, 2015(7), CD001751. doi:10. 1002/14651858. CD001751. pub3 Moriarty Daley, A., & Fender, T. (2011). Case 5. 4 Menstrual cramps. In L. Neal‐Boylan (Ed. ), Clinical case studies for the family nurse practitioner (pp. 147-150). Wiley. Nemours Foundation. (2019). All about menstruation. Retrieved from
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Menstrual Cramps 381 Osayande, A. S., & Mehulic, S. (2014). Diagnosis and initial management of dysmenorrhea. American Family Physician, 89(5), 341-346. https://www. aafp. org/afp/2014/0301/p341. html Steenland, M. W., Zapata, L. B., Brahmi, D., Marchbanks, P. A., & Curtis, K. M. (2013). Appropriate follow up to detect potential adverse events after initiation of select contraceptive methods: A systematic review. Contraception, 87(5), 611-624. doi:10. 1016/j. contraception. 2012. 09. 017 Upadhya, K. K., Santelli, J. S., Raine‐Bennett, T. R., Kottke, M. J., & Grossman, D. (2017). Over‐the‐counter access to oral contraceptives for adolescents. Journal of Adolescent Health, 60(6), 634-640. https://doi. org/10. 1016/j. jadohealth. 2016. 12. 024 Zannoni, L., Giorgi, M., Spagnolo, E., Montanari, G., Villa, G., & Seracchioli, R. (2014). Dysmenorrhea, absen-teeism from school, and symptoms suspicious for endometriosis in adolescents. Journal of Pediatric and Adolescent Gynecology, 27(5), 258-265. https://doi. org/10. 1016/j. jpag. 2013. 11. 008 Zhang, F., Sun, M., Han, S., Shen, X., Luo, Y., Zhong, D., Zhou, X., Liang, F., & Jin, R. (2018). Acupuncture for primary dysmenorrhea: An overview of systematic reviews. Evidence‐Based Complementary & Alternative Medicine (ECAM), 1-11. doi:10. 1155/2018/8791538
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383 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? A urine pregnancy test should be ordered. Genny should also be offered STI testing, including HIV testing and counseling with a history of unprotected sex. A Pap smear is recommended 3 years after the onset of sexual activity or by age 21, so it is not appropriate for Genny at this time. If the pregnancy test is positive, in the absence of symptoms, delaying the pelvic exam until a consultation with an obstetrician or at a termination appointment is appropriate. If there is a question regarding gestation, due to uncertainty with dates or irregular menstruation, referral for a pelvic exam and/or an ultrasound to determine dates is warranted (Hornberger, 2017). If Genny's pregnancy test is negative today, she should return for a repeat test in 2-4 weeks if she has no menses (ACOG, 2017). Why is it important to ask Genny what she feels her boyfriend would want if she were pregnant? The perceived desire of the partner is an important influence on pregnancy (Moriarty Daley & Fender, 2011). Counseling may help Genny negotiate the use of condoms by her male partner to avoid an unintended pregnancy (Pereira, Pires, Araújo‐Pedrosa, & Canavarro, 2018). In addition, engaging fathers in prenatal and infant care is essential in promoting involvement and decreasing parenting stress (Magness, 2012). What additional questions should Genny be asked? “How would you feel about a positive or negative pregnancy test today?” “How do you think your partner would react to a positive or negative pr egnancy test?” “Do you have any additional signs or symptoms, such as lower abdominal pain, breast tender-ness, nausea, vomiting, or fatigue?” “Have you talked to anyone about your possible pregnancy?” “Is there a supportive adult with whom you could discuss a positive pr egnancy test?” “Do you know what your 3 options are if the test is positive?” “What would you do if the test is positive today?”Case 5. 4 Missed Periods
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384 Resolutions “How will pregnancy af fect your living situation? Your education? Your employment?” “If the test is negative, would you like to begin a more ef fective contraception?” If Genny is pregnant today, what are her options? Educate Genny on her options regarding the pregnancy in a factual, respectful, nonjudgmental and adolescent‐friendly manner. The American Academy of Pediatrics first published a policy state-ment on options counseling in 1989, which has continued to be reaffirmed (Hornberger, 2017). Options counseling can be done at the first visit or over several future visits. Maintain confidenti-ality and give Genny the results of her test alone first, then give her an opportunity to discuss her feelings, pregnancy, and contraception options without a parent or guardian present initially (ACOG, 2017; Hornberger, 2017). However, parental involvement is often necessary, both emotion-ally and financially, so encouragement to share positive test results and involve parents with Genny's decision is important. If parental support is not possible or likely, encourage Genny to seek involvement of another trusted adult. Depending on the stage of pregnancy, there are 3 options: (1) continuing the pregnancy and raising the infant; (2) continuing the pregnancy to delivery and then having an adoption plan; or (3) terminating the pregnancy (Hornberger, 2017). Offer additional visits with her supportive adult, the male partner, her parents, or her partner's parents, if desired. Emphasize that the decision is time‐sensitive, and options may depend on gestational age. Should contraception be prescribed today? Condoms and an advance prescription for emergency contraception (Plan B) should be provided at this visit. Emergency contraception should be offered if the adolescent has had unprotected sex in the past 5 days and does not desire pregnancy (Hornberger, 2017). In addition, if she has a neg-ative pregnancy test, a prescription for hormonal contraception can be given today with clear instructions on how to start if she begins her menstrual cycle. If she desires injectionable contracep-tion (depot medroxyprogesterone acetate (DMPA)), she should call at the onset of her period to begin injections. Consider family history, coexisting medical conditions, and current medications when offering contraception options. Patient choice should be the primary factor in prescribing one method over another (ACOG, 2017). Contraception counseling should include reproductive goals, awareness of unprotected intercourse risks, efficacy and failure rates of different contraceptive methods, adverse effects and risks, ease of use, and additional barrier methods needed to prevent STIs (ACOG, 2017; Pereira et al., 2018). As contraceptive failures are often reported in unplanned pregnancy (such as condom rupture or forgetting to take a pill), backup methods and emergency contraception should also be discussed (Pereira et al., 2018). Long‐acting reversible contraceptives (LARCs) are the most effective form of birth control (Fernandez, 2017) and should be offered and discussed with Genny. LARC methods are easier for the patient to manage, as they do not require a daily, weekly, or monthly action by the patient (Fernandez, 2017). Initiation of implants or IUDs can occur immediately after delivery, pregnancy loss, or abortion, and in the case of a negative pregnancy test, if there is reasonable certainty that Genny is not pregnant (ACOG, 2017). “Quick start” initiation the same day can be with the implant, DMPA, and OCPs, and benefits likely exceed any risk (ACOG, 2017). The American College of Obstetricians and Gynecologists' clinical guidance is available online at www. acog. org. What health education should be provided to this patient? Community resources for each pregnancy option are helpful, and are dependent on rural or urban demographic area. It is important to make sure Genny has the appropriate services, financial resources, and social support for whatever her decision may be. For patients choosing to maintain their pregnancy, education regarding understanding preg-nancy and placing them in contact with an OB/GYN is imperative. Prescribe prenatal vitamins,
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Missed Periods 385 review health education regarding signs and symptoms of miscarriage and infection, and review when to call an OB/GYN and/or go to the emergency room early in pregnancy. Discuss ways to increase success in preventing pregnancy and sexually transmitted infections. Offer STI/HIV testing, to include HIV, syphilis, chlamydia, and gonorrhea, and, if maintaining pregnancy, Hepatitis B (Hornberger, 2017). Screening for STIs should be done at the time of counseling or LARC insertion (Fernandez, 2017). Addressing adolescent reproductive health care needs with a combination of health and sexuality education and contraceptive‐promoting interven-tions can decrease risk of unplanned adolescent pregnancy (Klein & Ray, 2017; Pereira et al., 2018). Consider peer teaching with active learning, examples, and visual aids to promote empowerment and patient understanding (Magness, 2012). Are there technologies available to assist this patient in managing or understanding her menstruation? Promote adherence to contraception through use of cell‐phone or electronic reminders (ACOG, 2017). Many online websites assist the patient in identifying which contraceptive method would be best for their lifestyles. Many resources are available for pregnancy and sexual health education. Examples include ACOG's patient information site (available at https://www. acog. org/Patients) and the National Campaign to Prevent Teen and Unplanned Pregnancy (available at powertode-cide. org and www. bedsider. org; National Campaign, 2019). The advent of apps useful in health care is also a resource for teens with smartphones, including period tracker and pregnancy tracker apps; examples include Flo, Glow, Ovia, and Clue. Awareness of data collection through apps should be expressed to adolescents (Kresge, Khrennikov, & Ramli, 2019) with emphasis on privacy settings. REFERENCES AND RESOURCES American College of Obstetricians and Gynecologists. (2017, May). Committee opinion: Adolescent pregnancy, contraception, and sexual activity. Retrieved from https://www. acog. org/Clinical‐Guidance‐and‐ Publications/Committee‐Opinions/Committee‐on‐Adolescent‐Health‐Care/Adolescent‐Pregnancy‐ Contraception‐and‐Sexual‐Activity American College of Obstetricians and Gynecologists. (2019). The ACOG patient page. Retrieved from https://www. acog. org/Patients Fernandez, S. (2017). Long‐acting reversible contraception: A primer for the primary care pediatrician. Pediatric Annals, 46(3), 79-82. https://doi‐org. 10. 3928/19382359‐20170220‐03 Hornberger, L. L. (2017). Diagnosis of pregnancy and providing options counseling. Pediatrics, 140(3), 1-9. https://doi‐org. 10. 1542/peds. 2017‐2273 Klein, D. A., & Ray, M. E. (2017). Preventing unintended adolescent pregnancy. American Family Physician, 95(7), 422-423. Retrieved from https://www. aafp. org/afp/2017/0401/p422. html Kresge, N., Khrennikov, I., & Ramli, D. (2019, January 24). Period‐tracking apps are monetizing women's extremely personal data: More than 100 million women monitor their cycles on their phones. Here come the ads. Bloomberg Businessweek. Retrieved from https://www. bloomberg. com/news/articles/2019‐01‐24/how‐period‐tracking‐apps‐are‐monetizing‐women‐s‐extremely‐personal‐data Magness, J. (2012). Adolescent pregnancy: The role of the healthcare provider. International Journal of Childbirth Education, 27(4), 61-64. Moriarty Daley, A., & Fender, T. (2011). Case 5. 4 Menstrual cramps. In L. Neal‐Boylan (Ed. ), Clinical case studies for the family nurse practitioner (pp. 147-150). Hoboken, NJ: Wiley. National Campaign to Prevent Teen and Unplanned Pregnancy (2019). The power to decide. Retrieved from https://powertodecide. org/ and https://www. bedsider. org/ Pereira, J. I. F., Pires, R. S. A., Araújo‐Pedrosa, A. F., & Canavarro, M. C. C. S. P. (2018). Reproductive and relational trajectories leading to pregnancy: Differences between adolescents and adult women who had an abortion. European Journal of Obstetrics & Gynecology & Reproductive Biology, 224, 181-187. https://doi‐ org. 10. 1016/j. ejogrb. 2018
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387 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION Given the information provided, what other questions would you ask? When deciding which contraceptive options would be the best choice for a patient, knowledge of any contraindications to specific contraceptive types is essential. Gathering a thorough past med-ical history and family medical history would be appropriate at this time. A family medical history related to coagulation disorders and cancer may affect any diagnostic tests or screenings the provider would choose to complete with the patient if hormonal contraceptives ar e being consid-ered. Obtaining this information may be difficult with the adolescent patient or a poor historian, and may require the involvement of other family members to ensure that no relative or absolute contraindications are present prior to prescribing. Smoking status should be considered with prescription of hormonal contraceptives, but it is not a contraindication unless the patient is 35 years old or older and smokes 15 or more cigarettes per day. This should include vaping or juuling as well. Screening for other substance use is equally important, as adolescents under the influence are more likely to participate in risky sexual behav-iors, including an inability to provide consent for intercourse. Ask the patient the regularity of her periods as well as frequency of sexual activity and last date of intercourse. She has disclosed that she uses condoms always for intercourse, but screening for proper use should also be part of the dialogue when reviewing contraceptive options. Be sure to give positive feedback as well for any contraceptive use if applicable. It is also important for the provider to determine in mutual decision‐making what the patient's goals are related to her contraceptive choices, such as shorter bleeding time, no periods, or not having to take a pill daily. Future family planning should also be assessed during contraceptive decision‐making. While the adolescent patient may not have family planning in mind at the time of the visit, it is important to assess whether they are planning to ever become pregnant, to become pregnant in the near future, or to become pregnant many years from the time of the visit. It is easy to assume that the teen may want to avoid pregnancy for many years, but this assump-tion could lead to a bias in recommendations for contraceptive options and may affect the rapport established between the pr ovider and patient if that teen does desire to become pregnant in the near future. Case 5. 5 Birth Control Decision‐Making
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388 Resolutions What diagnostic or screening tests would you consider running on this patient? Minimal diagnostic and screening tests are required for the healthy adolescent patient asking to start contraceptives. Determining pregnancy status is the most important screening to complete prior to starting contraceptives, and determines when a contraceptive can be initiated. A provider can be reasonably certain that a patient is not pregnant if it has been 7 or fewer days since their last menses, they have not had intercourse since their last menses, they have been using other contra-ceptive methods reliably, it has been 7 or fewer days since a spontaneous or induced abortion, they are within 4 weeks postpartum, or they are fully or near fully breastfeeding with amenorrhea and less than 6 months postpartum. A urine pregnancy test can be obtained to corroborate the history provided by the patient, but timing of menses and ovulation must be taken into account and a repeat test may be required 2-4 weeks later. A beta pregnancy test would be unnecessary at this time unless the patient were to miss their next menstrual cycle. STD testing should be encouraged and completed at the time of the visit when discussing con-traceptives. A urine gonorrhea and chlamydia test is an easy, noninvasive test to diagnose more two more common STDs in adolescents. Consideration of serum testing for HIV and syphilis may also be appropriate. For this patient it would be unnecessary as she is asymptomatic, uses condoms regularly with intercourse, and does not have a high‐risk sexual history of multiple partners or partners of the same sex/homosexual male partners. That being said, it is up to the patient and provider to decide which tests are most appropriate. A pelvic exam would only be necessary in an adolescent patient who has decided to use an intrauterine device (IUD) as their form of birth control. The provider would need to be qualified in performing this procedure and complete a bimanual and cervical exam. A Pap smear is not required until the patient is 21 years old, regardless of sexual history, based on guidelines from the 2009 rec-ommendations of the American College of Obstetricians and Gynecologists. Invasive cervical can-cer has been determined to be rare in those less than 21 years old and the younger female population tends to have high rates of minor change in cytology, leading to further unnecessary and invasive testing with higher risks both immediately and in consideration of future family planning. Obtaining bloodwork for a CBC and lipid panel is not necessary but may influence the provider and patient in deciding which method of contraception is appropriate based on side effects. For example, a CBC displaying a low hemoglobin level may lead the provider to test further for iron defi-ciency and determine whether a method that minimizes menstrual bleeding (duration and severity) or causes amenorrhea may be a good choice for that patient. Many combined oral contraceptive pills (OCPs) contain iron in the placebo week as well and may protect against any further deficiency. Neither would provide information that would contraindicate a specific contraceptive method. Lauren agrees to complete a urine pregnancy screening today, which is negative, and a urine GC/CT test is sent to the lab (which returns negative). She declines bloodwork at the time of the visit. What are the concerns at this point? While Lauren appears to be acting responsibly regarding her own sexual health, concerns today would be risk for unintended pregnancy and transmission of sexually transmitted infections. While male latex condom use can protect against both, there is a high failure rate with typical use and as many as 18 out of 100 women using condoms as their only contraceptive will become pregnant unintentionally each year. What is the diagnosis at this point? Healthy, sexually active adolescent female at risk for pregnancy and/or STIs. What types of contraceptives should be considered for Lauren? The initial decision regarding appropriate contraceptive options is to determine whether she pre-fers hormonal versus nonhormonal options. With a negative personal and family history, either would be appropriate. All are safe for nulliparous females.
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Birth Control Decision‐Making 389 Nonhormonal options include male latex condoms and the long‐acting reversible contraceptive (LARC) copper IUD (Paragard). Hormonal options include LARCs (Nexplenon implant, levonorg-estrol (LNG) IUDs such as Mirena or Skyla), Depo‐Provera (DMPA) injection, combined hormone contraceptives (OCPs, patch, and vaginal ring), progestin‐only pills (“minipill”), and emergency contraceptives (Plan B or Ella). Ideally, the provider would present each option from most effective (LARCs such as the implant or IUDs) to least effective and provide education regarding administration of each method. Assessing possible barriers to each form of contraception is essential to maintain compliance and prevent unwanted pregnancies. This would be a great time to assess Lauren's comfort with invasive procedures (implant or IUD), comfort with her own body (insert-ing a vaginal ring), and desires for dosing frequency (not wanting to take a pill every day) or avail-ability for follow‐up visits. If she is not able to return for follow‐ups at least every 3 months, DMPA injections would not be a good option for her. Exploring confidentiality and a desire to involve parents/guardians at this time will also affect which contraception method is the best fit for her. Cost may affect this decision as well, especially if parental involvement is not preferred. How would each contraceptive option be initiated? The “quick start” method for most contraceptives is preferred to increase adherence. Initiating the con-traceptive on the day of the visit would be appropriate for most patients as long as there is reasonable certainty that pregnancy has been ruled out. Knowing the date of the start of the last menstrual period (LMP) as well as the date of last unprotected intercourse is necessary to make this determination. IUDs: If the patient had unprotected sexual inter course within 5 days of the appointment, the copper IUD can be inserted as an emergency contraception option as well as for future preg-nancy prevention. Pregnancy must be ruled out if it has been greater than 5 days since last unprotected intercourse and the patient is not currently menstruating. If unsure, another form of contraception can be initiated until the next menstrual cycle and the patient could then return for IUD insertion. The copper IUD does not require any back‐up method after insertion. LNG IUDs require back‐up contraception or abstaining from intercourse for 1 week if it has been greater than 7 days since their LMP. Implant (Nexplenon): The implant can be inserted on the same day as the initial visit when it is reasonably certain that the patient is not pr egnant. If uncertain, benefits of inserting outweigh possible risks and the implant can still be inserted that day with a follow‐up pregnancy test in 2-4 weeks. Backup contraception or abstaining from intercourse for 1 week is recommended if it has been greater than 5 days since LMP. DMPA (Depo‐Provera) injection: The injection can be given at the time of the visit if the health care provider is reasonably certain that the patient is not pregnant. If uncertain, the injection can be given with a follow‐up urine pregnancy test in 2-4 weeks. Backup contraception or abstain-ing from intercourse for 1 week is recommended if it has been greater than 7 days since the patient's LMP. The injection is then repeated every 13 weeks (3 months), although it can be given earlier, and for the adolescent population, appointments should be scheduled 11-12 weeks out in case of missed or delayed appointments. If it has been greater than 15 weeks bet-ween doses, reconfirmation of negative pregnancy status is required and backup contraception is recommended for 1 week following repeat injection. Combined hormonal contraceptives (OCPs, patch, vaginal ring): Quick start on day of visit if desired and patient is not pregnant. If uncertain, start and have patient return in 2-4 weeks for pregnancy test. Backup contraception or abstaining from intercourse is recommended if it has been 5 or more days since LMP. These methods can also be started on the first day of the next menstrual cycle, or using the “Sunday start” method, meaning the patient would begin on the Sunday after the start of their next menstrual cycle. An OCP will then need to be taken every day at the same time. The patch is applied once a week for 3 weeks, then removed for 1 week to allow for a withdrawal bleed. The vaginal ring is inserted and remains in place for 3 weeks, then is removed for 1 week prior to inserting a new ring.
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390 Resolutions Progestin‐only pill (mini‐pill): Quick start on day of visit when it is reasonably certain that the patient is not pr egnant. If uncertain, pills can be initiated and patient should return in 2-4 weeks to repeat pregnancy test. Backup contraception or abstaining from intercourse is recom-mended for 2 days if it has been greater than 5 days since LMP. The progestin‐only pill must be taken at the same time each day for maximum effectiveness, and backup would be required for 2 days even if the pill is taken later than 3 hours after intended. Emergency contraception (Plan‐B, Ella): Medication is to be taken within 5 days of unpr otected intercourse. While Plan‐B (levonorgestrel) is most effective 1-3 days after unprotected intercourse, Ella (Ulipristal) is more effective than Plan‐B on days 3-5. Ella requires a prescription, but levonorgestrel emergency contraception can be purchased over the counter from a pharmacist. What are some common contraindications to contraceptives? While most contraceptive options are considered very safe, certain medical conditions can exacer-bate possible adverse effects of these medications. While some are relative risks, a few are absolute contraindications in which the risks of potential adverse effects outweigh the benefits. It is impor-tant to consider when working with an adolescent with chronic medical issues that the risks of pregnancy may be greater than the risks of using contraceptives, and collaboration with their spe-cialists is essential to ensure safe and effective treatment for that teen. IUDs: Anatomical abnormalities of the uter us, acute pelvic infection, known or suspected preg-nancy, Wilson disease (copper IUD), undiagnosed vaginal bleeding, breast cancer (LNG‐IUD), and hepatocellular adenoma or hepatoma (LNG‐IUD). Implant (Nexplenon): Known or suspected pregnancy, severe cirrhosis, hepatocellular ade-noma or hepatoma, undiagnosed vaginal bleeding, systemic lupus erythematosus with antiphospholipid antibodies, and breast cancer (known, suspected, or history of). DMPA (Depo‐Provera): Cardiovascular disease (and risk factors), severe hypertension, ischemic heart disease or stroke, systemic lupus erythematosus with thrombocytopenia and/or antiphos-pholipid antibodies, undiagnosed vaginal bleeding, breast cancer, diabetes with vascular com-plications, severe cirrhosis, and hepatocellular adenoma or hepatoma. CHCs (OCPs, patch, ring): Arterial car diovascular disease, hypertension, ischemic heart disease or stroke, known thrombophilia or thrombogenic mutations (coagulation disorders), history of deep vein thrombosis or pulmonary embolism, superficial venous thrombosis (current or history of), increased risk of thromboembolism (post‐op, <21 days postpartum), complicated valvular heart disease, migraine with aura, breast cancer, complicated diabetes with vascular changes, medically treated gallbladder disease, acute viral hepatitis, history of surgery for obesity with malabsorption procedure, and drug interactions (few antiretroviral therapies, anticonvulsants, rifampin). How should Lauren be counseled about side effects? Possible side effects should be discussed with the patient at the initial visit as well as with each follow‐up visit. When a patient experiences a side effect of a contraceptive method that they were not prepared for, this can decrease adherence or cause the patient to discontinue the method on their own, putting them at risk for unintended pregnancies. Weight gain is often the most concerning side effect that adolescents worry about related to contra-ceptive use, but evidence shows that weight changes are typically not related to contraceptives with the exception of the DMPA injection. Diet and exercise counseling should be provided at all contraceptive visits when weight gain is suspected and of any concern to the patient or provider. A baseline weight should be obtained at the first contraceptive visit and monitored with each follow‐up appointment. IUD: Irr egular menstrual bleeding and/or cramping (heavy bleeding is more typical with the copper IUD, while irregular spotting is more common with the LNG‐IUD and may lead to amenorrhea), infection (risk higher only in the first 21 days post‐insertion), expulsion, perfora-tion, pregnancy (ectopic or intrauterine, with both being rare).
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Birth Control Decision‐Making 391 Progestin‐related side effects with the LNG‐IUD are less common due to low circulating levonor gestrel levels, but can cause acne, weight changes, hirsutism, headaches, nausea, and mood changes in females who are sensitive to hormone changes. Implant: Irregular menstr ual bleeding, amenorrhea, headache, weight changes, acne, abdom-inal pain, breast tenderness, mood changes, local site reaction. DMPA injection: Local site reaction, irregular menstrual bleeding, amenorrhea, weight gain/ increased appetite, headache, mood changes, decreased bone mineral density (reversible with discontinuation, but important to counsel regarding calcium/vitamin D intake or supplementation). CHCs (OCPs, patch, ring): Breast tenderness, nausea, bloating, irregular menstrual bleeding (typically resolves within first 3 months of use), local site reaction with patch, leukorrhea and vaginitis with ring. Progestin‐only pill: Irr egular menstrual bleeding, acne. Emergency contraceptives: Headache, abdominal pain, nausea, menstr ual changes, fatigue, dizziness, breast tenderness. Condoms: Local site reaction/aller gy to components. What are the plans for referral and follow‐up care? Follow‐up and referral is dependent on the setting of the initial contraceptive counseling visit and the provider's comfort and training with each method. If the adolescent is seen at their primary care pediatric office, contraceptive methods being prescribed by that primary care provider may be limited due to training. A referral to an adolescent gynecologist would be appropriate when more invasive contraceptive methods are being considered, such as the implant or IUD, or if a patient is not tolerating another prescribed method. In adult medicine, routine follow‐up for contraceptives is not recommended unless there are specific concerns. Working with adolescents typically requires closer, more frequent follow‐up to screen for compliance and side effects, as well as assess the adolescent's satisfaction with their chosen contraceptive method. These visits also provide additional opportunities to educate the patient further on reproductive health. What other education should Lauren be provided with related to reproductive health? Reinforcing safe sex practices is essential during each contraceptive visit with the adolescent. She should be encouraged to continue use of condoms even with other contraceptives on board, as con-doms are the only way to further protect her from STIs. Proper condom use should be reviewed with her as well during the visit to ensure as close to perfect use as possible. Reviewing how STIs are spread is imperative as well, since many teens engage in risky sexual behaviors but only use condoms for penile‐vaginal penetration. If she has not received the human papilloma virus (HPV) vaccine already, this would be an essential time to provide counseling to the patient (and parent if possible) to ensure that every step is being taken to protect her from future malignancy secondary to contracting HPV at a young age. If the patient chooses not to discuss her choice to seek out birth control options with her mother, how would you proceed? Adolescent confidentiality can provide for excellent rapport between a provider and teen patient, but can be a source of contention when a parent is seeking out confidential information regarding their adolescent child. The adolescent patient is more likely to share information regarding their reproductive health with the knowledge that what they disclose will remain between the provider and patient. Explaining confidentiality, including times where a breach in confidentiality would be required (disclosures of abuse, suicidal ideation, and/or homicidal ideation) to the patient at the start of each visit is important to maintaining a trusting relationship.
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392 Resolutions Reproductive health and adolescent confidentiality can be considered more complex in that the teen's ability to consent to reproductive care and contraceptives is regulated by state laws. A teen can consent to STI testing and treatment in every state. Providers should familiarize themselves with their state laws regarding consent for contraceptives and use these to guide patients to the safest, most effective way for the teen to obtain contraceptives. Open communication should be promoted between the teen and their parent/guardian. Are there any standardized guidelines that should be used to treat this case? If so, what are they? The Centers for Disease Control (CDC) and World Health Organization (WHO) provide many guidelines not only for the prescribing and initiation of contraceptives in the general population, but also for those with other medical conditions. The CDC also provides guidance for providers during special circumstances, such as when a patient who takes OCPs misses their pills or when a patient with an IUD is diagnosed with pelvic inflammatory disease. The American Academy of Pediatrics (AAP) has also developed a policy statement with guidance for prescribing contracep-tives to teen patients. U. S. Medical Eligibility Criteria for Contraceptive Use (CDC, 2016) U. S. Selected Practice Recommendations for Contraceptive Use (CDC, 2016) Medical eligibility criteria for contraceptive use (WHO, 2015) Policy Statement: Contraceptive for Adolescents (AAP, 2014) REFERENCES Abma, J. C., & Martinez, G. M. (2017). Sexual activity and contraceptive practices among teenagers in the United States, 2011-2015. National Health Statistics Report. Retrieved June 25, 2019, from https://www. cdc. gov/nchs/data/nhsr/nhsr104. pdf American Academy of Pediatrics. (2014). Policy statement: Contraception for adolescents. Pediatrics. doi:10. 1542/peds. 2014‐2299 Aoun, J., Dines, V. A., Stovall, D. W., Mete, M., Nelson, C. B., & Gomez‐Lobo, V. (2014). Effects of age, parity, and device type on complications and discontinuation of intrauterine devices. Obstetrics & Gynecology, 123(3). doi:10. 1097/AOG. 0000000000000144 Callegari, L. S., Aiken, A. R., Dehlendorf, C., Cason, P., & Borrero, S. (2017). Addressing potential pitfalls of reproductive life planning with patient‐centered counseling. American Journal of Obstetrics and Gynecology, 216(2), 129-134. doi:10. 1016/j. ajog. 2016. 10. 004 Centers for Disease Control and Prevention. (2016). U. S. medical eligibility criteria for contraceptive use, 2016. Morbidity and Mortality Weekly Report, 65(3). https://www. cdc. gov/mmwr/volumes/65/rr/pdfs/rr6503. pdf. Centers for Disease Control and Prevention. (2016). U. S. selected practice recommendations for contraceptive use, 2016. Morbidity and Mortality Weekly Report, 65(4). https://www. cdc. gov/mmwr/volumes/65/rr/ pdfs/rr6504. pdf Darney, P., Patel, A., Rosen, K., Shapiro, L. S., & Kaunitz, A. M. (2009). Safety and efficacy of a single‐rod etono-gestrel implant (Implanon): Results from 11 international clinical trials. Fertility and Sterility, 91(5). doi:10. 1016/j. fertnstert. 2008. 02. 140 Diedrich, J. T., Desai, S., Zhao, Q., Secura, G., Madden, T., & Peipert, J. F. (2015). Association of short‐term bleeding and cramping patterns with long‐acting reversible contraceptive method satisfaction. American Journal of Obstetrics and Gynecology, 212(1). doi:10. 1016/j. ajog. 2014. 07. 025 Foxx, A., Zhu, Y., Mitchel, E., Khabele, D., Griffin, M. R., & Nikpay, S. (2018). Cervical cancer screening and follow‐up procedures in women age <21 years following new screening guidelines. Journal of Adolescent Health, 62, 170-175. doi:10. 1016/j. jadohealth. 2017. 08. 027 Hubacher, D., Lopez, L., Steiner, M. J., & Dorflinger, L. (2009). Menstrual pattern changes from levonorgestrel subdermal implants and DMPA: Systematic review and evidence‐based comparisons. Contraception, 80(2), 113-118. doi:10. 1016/j. contraception. 2009. 02. 008
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Birth Control Decision‐Making 393 Jain, J., Jakimiuk, A., Bode, F., Ross, D., & Kaunitz, A. (2004). Contraceptive efficacy and safety of DMPA‐SC. Contraception, 70(4), 269-275. doi:10. 1016/j. contraception. 2004. 06. 011 Kavanaugh, M., Frohwirth, L., Jerman, J., Popkin, R., & Ethier, K. (2013). Long‐acting reversible contraception for adolescents and young adults: Patient and provider perspectives. Journal of Pediatric and Adolescent Gynecology, 26(2). doi:10. 1016/j. jpag. 2012. 10. 006 Lopez, L. M., Edelman, A., Chen, M., Otterness, C., Trussell, J., Helmerhorst, F. M., & Ramesh, S. (2016). Progestin‐only contraceptives: Effects on weight. Cochrane Database of Systematic Reviews. doi:10. 1002/14651858. CD008815. pub4 Lopez, L. M., Gallo, D. A., Gallo, M. F., Stockton, L. L., & Schultz, K. F. (2013). Skin patch and vaginal ring versus combined oral contraceptives for contraception. Cochrane Database Systematic Reviews. doi:10. 1002/14651858. CD003552. pub4 Marcell, A. V., & Burstein, G. R. (2017). Sexual and reproductive health care services in the pediatric setting. Pediatrics, 140(5). doi:10. 1542/peds. 2017‐2858 Pfizer, Inc. (n. d. ). DEPO‐PROVERA—medroxyprogesterone acetate injection, suspension. Retrieved June 27, 2019, from http://labeling. pfizer. com/Show Labeling. aspx?id=522 Pritt, N. M., Norris, A. H., & Berlan, E. D. (2017). Barriers and facilitators to adolescents' use of long‐acting reversible contraceptives. Journal of Pediatric and Adolescent Gynecology, 30(1). doi:10. 1016/j. jpag. 2016. 07. 002 Shapiro, S., & Dinger, J. (2010). Risk of venous thromboembolism among users of oral contraceptives: A review of two recently published studies. Journal of Family Planning and Reproductive Health Care, 36(1), 33-38. doi:10. 1783/147118910790291037 Steiner, M. J., Trussell, J., Mehta, N., Condon, S., Subramaniam, S., & Bourne, D. (2006). Communicating con-traceptive effectiveness: A randomized controlled trial to inform a World Health Organization family planning handbook. American Journal of Obstetrics and Gynecology, 195(1), 85-91. doi:10. 1016/j. ajog. 2005. 12. 053 U. S. FDA Prescribing Information. (2017, September). Plan B (levonorgestrel). https://www. accessdata. fda. gov/drugsatfda_docs/label/2017/021045s016lbl. pdf U. S. Food and Drug Administration (FDA) approved product information. (2018, October 5). NEXPLANON— etonogestrel implant. Retrieved June 27, 2019, from https://dailymed. nlm. nih. gov/dailymed/drug Info. cfm?setid=b03a3917‐9a65‐45c2‐bbbb‐871da858ef34 U. S. Food and Drug Administration (FDA) approved product information. (2018, December 18). NORETHINDRONE ACETATE—norethindrone tablet. Retrieved June 27, 2019, from https://dailymed. nlm. nih. gov/dailymed/drug Info. cfm?setid=64cb920c‐36e8‐4d62‐9d08‐3ddf3989d313 U. S. Food and Drug Administration (FDA) approved product information. (2018, June 8). ELLA—ulipristal acetate tablet. Retrieved June 27, 2019, from https://dailymed. nlm. nih. gov/dailymed/drug Info. cfm?setid=052bfe45‐c485‐49e5‐8fc4‐51990b2efba4 Westhoff, C. L., Heartwell, S., Edwards, S., Zieman, M., Stuart, G., Cwiak, C., . . . . . . Robilotto, T. (2007). Oral contraceptive discontinuation: Do side effects matter? American Journal of Obstetrics and Gynecology, 196(4). doi:10. 1016/j. ajog. 2006. 12. 015 World Health Organization. (2015). Medical eligibility criteria for contraceptive use (5th ed. ). Geneva: Department of Reproductive Health and Research, World Health Organization. Retrieved June 24, 2019, from https://www. who. int/reproductivehealth/publications/family_planning/MEC‐5/en/.
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395 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION Which diagnostic studies should be considered to assist with or confirm the diagnosis? NAAT for chlamydia/gonorrhea: diagnostic for chlamydia. Wet mount: p H = 3. 9, Negative whif f test, WBCs present but no clue cells or trichomonads. Urine HCG: negative. HIV offer ed but refused this visit. RPR offer ed but refused this visit. What is the most likely differential diagnosis and why? Chlamydia (uncomplicated genital): Chlamydia is often asymptomatic; however, Nora's symptoms of cloudy, mucoid discharge and intermenstrual spotting are indicative of infection. What is the plan of treatment? Nora will be treated with Azithromycin 1 gm orally for a single dose as recommended for treatment of uncomplicated chlamydia. Doxycycline 100 mg, BID × 7 days is an effective alternative, although compliance may be an issue. How should this patient be counseled regarding the prevention of STIs? Nora should be educated regarding the signs and symptoms of STIs. She should be reminded that STIs may be asymptomatic, making risk reduction and prevention essential. Discuss risk reduction including abstinence, monogamy, and condom use. Counsel Nora about correct and consistent condom use and subsequent reduction of any risk of recurrent chlamydia and/or other STIs. Remind her that this is a responsibility of both her and her partner. Counsel her about contracep-tion options. She should be informed that hormonal contraception does not protect against STDs and HIV. Give Nora printed information about HIV testing and inform her that effective treatment for chlamydia may reduce susceptibility but not prevent transmission of HIV. Tell Nora that chla-mydia is a reportable disease in all 50 states. Case 5. 6 Vaginal Discharge
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396 Resolutions Is this patient at risk for HIV? Risk for HIV exists in the presence of multiple partners and unprotected sex along with a diag-nosed STI, including chlamydia. Should this patient be retested for cure following treatment? Nora should return for follow up testing in 3 months. The Centers for Disease Control recommends that all male or female persons with diagnosed chlamydia be rescreened in 3 months after initial treatment. This is recommended even if the patient believes that all partners have been treated. Chlamydia reinfection may occur in up to 1 in 5 individuals after treatment for initial infection. Should this patient's partners be treated? All partners within the past 60 days should be treated. Nora should be encouraged to tell all part-ners of her diagnosis to prevent reinfection of herself or others. If Nora expresses anxiety about partner treatment, explain that expedited partner therapy (EPT) is an option. (This option is state‐specific, so check in your state). REFERENCES AND RESOURCES World Health Organization. 2016. WHO guidelines for the treatment of chlamydia trachomatis World Health Organization. Available from: https://www. ncbi. nlm. gov/books/NBK379707/ Papp, J. R., Schachter, J., Gaydos, C. A., & Van Der Pol, B. (2014). Recommendations for the laboratory‐based detection of Chlamydia tracomatis and Neisseria gonorrhoeae-2014. MMWR Recommendation Report, 63,1-19. Workowski, K. A., & Bolan, G. A. (2015). Sexually transmitted diseases treatment guidelines-2015. MMWR Recommendation Report, 64(RR‐03), 1-137.
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397 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION What concerns should be addressed at this visit and why? 1. Sexual identity: Michelle speaks clearly about her desire to present as a male. She again notes that she is not sexually active but is attracted to girls. This should be discussed in open, nonjudgmental conversation. Explain that sexual identity is not a diagnosis and that it is not necessary to be sex-ually active to define neither sexual orientation nor does being attracted to the same sex make one gay. Standard confidentiality practices for minor patients should be acknowledged but impli-cations of premature disclosure of sexual identity (e. g., rejection, alienation) must be considered. Allow Michelle to set the pace of disclosure. A confidentiality agreement should be established and she must be aware of when it may be broken. This agreement commits the provider to keeping conversations private unless the adolescent is at risk of self‐harm and/or harm of others. Trust is the basis for any future effective communication. 2. Anxiety/Depression: Explain the PHQ9 screening for depression and anxiety. Michelle should be aware that these screenings along with regular evaluation of safety are important concerns in adolescents with sexual identity issues. Encourage her to report any mood changes or neg-ative thoughts to an accepting, supportive individual and seek help. What case‐specific questions should be asked addressing Michelle's desire for amenorrhea ? Ask Michelle to discuss her desire to stop having menstrual periods. Understanding her reasoning is basic to understanding any gender dysphoria. Michelle does not express opposition to her true gender assignment nor does she want “boy hormones” (testosterone). She states that she does not want to change her body but that not having a period will improve her chosen lifestyle. Listen to her concerns. She asks if there are ways to stop her period with medications. Explain that amen-orrhea can be induced using continuous administration of oral contraceptive pills, progesterone‐only long‐acting reversible contraceptives (LARC) like depo‐medroxyprogesteron acetate injections, or a levonorgestrel intrauterine device (IUD). Review the side effects, risks, and benefits of each method. Explain that possibility of long‐term risks is unknown. Michelle tells you she has friends Case 5. 7 Sexual Identity
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398 Resolutions who use those methods for contraception. Encourage her to discuss the options with her mother or aunt and call with any questions. Are any referrals needed? A referral to a mental health professional who either specializes in, or is experienced with, gender issues is warranted. This is particularly important to help with feelings of depression, anxiety, or suicidal ideation. Michelle has described some depression and anxiety during your interview. It is also important to assist the adolescent with establishing a support system. This should include, in addition to adult family support, access to lesbian, gay, bisexual, transgender, queer (LGBTQ) groups. Michelle's rural area lacks support and inclusion groups at school or in the immediate community. Provide online sources and encourage her to look for groups outside the immediate community. What complications exist related to the rural setting? An LGBTQ lifestyle is less accepted in small rural areas than in urban cities. Safety is a primary concern for all LGBT people but is a greater concern in an unaccepting area where alternative lifestyles are not accepted. Access to wooded areas and firearms along with a decreased police presence should be considered. Bullying is a school concern and Michelle needs to be able to be open and report incidents to her mother or another support person. Assist and encourage Michelle to preserve family r elationships and open conversation. Are there implications for future medical care? Comprehensive health care is necessary to promote normal adolescent development and continued physical health. An adolescent who is not yet sexually active should be educated about increased risk of STI, HIV, and HPV in the LGBTQ community. What psychosocial challenges present with “coming out”? Michelle tells you she started having dreams and fantasized about being a boy a few years ago. She wants to start dressing as a male and having her hair cut “like a boy. ” She wants to be called “Mick” instead of Michelle and prefers the pronoun “they” but has not told others yet. It is important that they develop a healthy, integrated identity; however, this will be challenged by prejudice, negative stereotypes, and in some instances lack of societal and family support. The fact that they feel, and will look, different than their peers will cause some turmoil. They have to be prepared to cope with this in a safe and healthy manner. Some adolescents turn to substance abuse to deal with negative, upsetting situations. REFERENCES AND RESOURCES AACAP releases practice parameter on sexual orientation, gender nonconformity, and gender identity issues in children and adolescents. (2013, August 1). American Family Physician, 88(3),202-205. Higgins, J. A., & Smith, N. K. (2016). The sexual acceptability of contraception: Reviewing the literature and building a new concept. Journal of Sex Research, 53(4-5), 417-456.
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399 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION Which diagnostic tests should be ordered in this case and why? A CBC with differential can help indicate whether infection or malignancy is contributing to the patient's knee pain, as an elevated white blood cell (WBC) count would indicate infection. The CMP could be helpful in determining whether the liver and kidneys are functioning normally. In a case of Lyme disease, some transient elevation of liver enzymes can be found. ESR and CRP indi-cate inflammation and are nonspecific as to the cause of inflammation, but can help a provider determine how long inflammation has been present. An elevated rheumatoid factor and ANA can lead the provider toward a diagnosis of an autoimmune disorder, such as rheumatoid arthritis. It is important to note, however, that the ANA can be elevated in a majority of the population without significance. An LDH level indicates cell damage such as in a case of malignancy. The ELISA with reflex Western blot test for Lyme disease can be diagnostic of Lyme disease if completed at the appropriate time after exposure to the disease. Most patients will be seropositive 6 or more weeks after exposure. If the test is done too soon, there is an increased likelihood of false negatives. If symptoms have been present for <30 days, Ig M and Ig G Western blot testing is per-formed. If symptoms have been present for >30 days, only Ig G Western blot is performed. The Ig M blot is considered positive if 2 or more of 3 bands are present. The Ig G blot is considered positive if 5 or more bands of the 10 bands are present. Imaging can also be helpful in determining a diagnosis for knee pain and swelling. An X‐ray could assist a provider in determining whether trauma, injury, or malignancy is contributing to symptoms, and can rule out other diagnosis such as fractures, periostitis, avascular necrosis, bone tumors, and dysplasias. X‐rays can also show the degree of joint effusion, or fluid accumulation in the joint, that is present. An MRI is typically completed when there is suspected injury to soft tissues, and can confirm diagnosis such as a torn cruciate or collateral ligaments, or torn meniscus. A sample of synovial fluid, or fluid that has accumulated in the joint, can be diagnostic of the cause of the effusion. Cell counts such as an elevated WBC count would indicate an infection. A Gram stain, PCR, and culture/sensitivity can lead the provider to both a diagnosis and the most appropriate course of treatment. It is important to note that this is an invasive procedure. Case 5. 8 Knee Pain
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400 Resolutions Peter was sent to his local outpatient laboratory/imaging center for bloodwork and an X‐ray of his knee. His WBC count was mildly elevated with a left shift toward immature cells, which can indicate an infection. The CMP displayed normal liver and kidney functions. His CRP was normal, but a moderately elevated ESR level was indicative of an infectious or autoimmune process that has been present and causing inflammation for some time. His ANA and rheumatoid factors were both negative, and LDH was within normal limits. Peter's ELISA test was positive, so only an Ig G Western blot was performed due to the presence of symptoms (fatigue, headaches) for >30 days. Seven Ig G bands were detected, which is positive for Lyme disease that has been present for at least 6-8 weeks. An X‐ray of Peter's knee showed normal bone structure and spacing between bones with no fractures present, but demonstrated a significant joint effusion. An MRI or synovial fluid aspiration was not indicated at this time. An MRI may be suggested in the future if symptoms persist, and would likely be ordered and interpreted by a specialist such as an orthopedist. The same can be said regarding synovial fluid aspiration. If Peter were to become acutely ill or in need of inpatient care, synovial fluid aspiration may be warranted and an infectious disease team would be involved in this decision making. What is the most likely differential diagnosis and why? Based on the results of Peter's bloodwork and imaging, a diagnosis of Lyme arthritis is made. Oligoarthritis, commonly involving one large weight‐bearing joint, is the most common late man-ifestation of disseminated Lyme disease. Lyme disease is an infection caused by the bacteria Borrelia burgdorferi that is transmitted to humans via a bite from a deer tick. The highest prevalence of Lyme disease is in the Northeast and Mid‐Atlantic regions of the United States, and bites can be con-tracted from spending time in wooded areas. The tick must be attached for greater than 24 hours to transmit the infection. Because of the deer tick's small size and lack of pain associated with a bite, patients are often unable to recall the bite itself, as is the case with Peter. The most common initial sign of Lyme disease is the presence of the erythema migrans (EM), or “bull's‐eye” rash at the site of the bite. Based on Peter's history, the development of an EM rash may have occurred in a place with less visibility, such as on the scalp under hair or on the buttocks. What is the plan of treatment? In Peter's case, the focus should be on both treating the infection and symptom management. Antibiotics are indicated for treatment of Lyme disease, with Doxycycline being the drug of choice. Based on Peter's weight and age, as well as his diagnosis of late (versus early) disseminated Lyme disease, he would be instructed to start Doxycycline 100 mg by mouth twice daily for 28 days. Musculoskeletal symptoms would be expected to resolve within 1-3 months of antibiotic therapy, and approximately 90% of patients see resolution with one course of antibiotics. More severe symp-toms could result in hospitalization and IV antibiotic administration. Symptom management is often obtained through the use of nonsteroidal anti‐inflammatory drugs (NSAIDs) to address both pain and inflammation, and should be given with food to avoid gastrointestinal side effects. What are the plans for referral and follow‐up care? Early signs of Lyme disease can be treated and followed by the primary care provider. Involvement with specialists is sometimes warranted to assist in managing symptoms and treatment options in more progressive cases. In this case, referral to an orthopedist and infectious disease specialist could be beneficial for the patient to ensure that the infection is adequately treated and long‐term complications are avoided. A referral would be especially appropriate if symptoms are persisting past the initial 28‐day course of Doxycycline. What health education should be provided to this patient? Initially, education for this patient and family should focus on diagnosis and treatment options. The patient should receive thorough instructions regarding Doxycycline administration and the
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Knee Pain 401 importance of completing the full course of antibiotics, as well as common side effects such as esophagitis and allergic reactions. A key part of educating patients and families about tick‐borne illnesses lies in prevention. Minimizing exposure to ticks, especially during warmer months, is an important step in preventing tick‐borne illnesses. Centers for Disease Control and Prevention (CDC) recommendations should be reviewed with patients, including avoiding wooded areas with high grass, wearing insect repellent, wearing long sleeves/long pants in wooded areas with socks pulled over pant legs, and completing comprehensive tick checks on yourself, children, and pets after outdoor exposure, with careful examination of commonly missed places such as folds. What demographic characteristics might affect this case? The patient's ethnicity and gender do not affect this case. The age of the patient does affect treatment options. The education level of the patient should be taken into consideration no matter the diag-nosis when it comes to providing appropriate education and materials. The geographic location of the patient and family should be taken into account when consid-ering a differential diagnosis including tick‐borne illnesses. It is always important to ask about travel, especially in this case, where the patient lives in an urban setting (New York City) but was living in a rural setting working in an outdoor camp (Connecticut). While not present in this particular case, studies have found larger‐scale health disparities asso-ciated with Lyme disease in the United States. Areas of temporarily or permanently vacant homes (where rodents and other small mammals for tick species live) show increases in rates of infection among humans. Another possible factor is overgrown greening and lack of pest control. Another contrasting study showed evidence of reverse health disparity with Lyme disease, where the inci-dence was highest in counties with more socioeconomically advantaged populations and was pos-itively associated with population with a bachelor's degree or higher: the contrasting health disparities in this study remain unclear (Springer & Johnson, 2018). Are there any standardized guidelines that should be used to treat this case? If so, what are they? The American Academy of Pediatrics (AAP) Red Book contains up‐to‐date guidelines for diag-nosing and treating infectious diseases, including Lyme disease. The CDC also provides diagnosis and treatment guidelines for health care providers, as well as education for the general population. Is there any other information that would be helpful in determining a diagnosis? A comprehensive history, exam, and laboratory testing is most helpful in determining a diagnosis. Some information that could help direct a provider toward a clear diagnosis would be obtaining more information about Peter's time spent in the woods and whether he was performing tick checks, as well as a thorough review of systems and assessment of his pain, including what time of day and what activities exacerbate his knee pain. If this patient were 6 years old, would it change how he would be tested and treated? In a 6‐year‐old patient presenting with acute monoarticular arthritis, as with a patient of any age, testing is dependent on the severity and quality of symptoms. Serum laboratory screening would likely be ordered assessing for the same differential diagnosis to help determine the cause (infectious, injury, autoimmune, or malignancy) of the swelling and pain. Consideration of the child's developmental status would be important when considering imaging such as an MRI, where the child would have to remain still for an extended period of time. Synovial fluid testing is an invasive procedure that would possibly require sedation in a younger child, and would likely only be performed if the child were inpatient and if that information were pertinent to determining a diagnosis. If the child in the case were a 6‐year‐old who tested seropositive for Lyme disease, the antibiotic of choice is Amoxicillin due to concerns of tooth staining with Doxycycline use in young children. Children under 8 years old require Amoxicillin 50 mg/kg/day divided 3 times a day for treatment
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402 Resolutions of Lyme disease, with the duration of the course of antibiotics depending on their symptoms. Musculoskeletal symptoms such as arthritis still require a 28‐day course of antibiotics. At what point would inpatient treatment be more appropriate than outpatient for this patient? Inpatient treatment would be appropriate for this patient if the teen were experience more severe symptoms, such as prolonged high fevers (>104° F for >3 days) or inability to bear weight on the affected leg. A child with this severity of symptoms may require IV antibiotics as treatment as well, as more invasive testing (synovial fluid, lumbar puncture) to determine whether Lyme disease is the correct and only diagnosis causing symptoms for this patient. REFERENCES AND RESOURCES Agodi, A., Barchitta, M., Trigilia, C., Barone, P., Marino, S., Garozzo, R., . . . Cataldo, A. D. (2013). Neutrophil counts distinguish between malignancy and arthritis in children with musculoskeletal pain: A case-control study. BMC Pediatrics, 13(1). doi:10. 1186/1471‐2431‐13‐15 Bockenstedt, L. K., & Wormser, G. P. (2014). Unraveling Lyme disease. Arthritis & Rheumatology, 66(9), 2313-2323. doi:10. 1002/art. 38756 Centers for Disease Control. (2018, December 21). Preventing tick bites on people | Lyme disease. Retrieved June 17, 2019, from https://www. cdc. gov/lyme/prev/on_people. html Cruz, A. I., Aversano, F. J., Seeley, M. A., Sankar, W. N., & Baldwin, K. D. (2017). Pediatric Lyme arthritis of the hip. Journal of Pediatric Orthopaedics, 37(5), 355-361. doi:10. 1097/bpo. 0000000000000664 Daikh, B. E., Emerson, F. E., Smith, R. P., Lucas, F. L., & Mc Carthy, C. A. (2013). Lyme arthritis: A comparison of presentation, synovial fluid analysis, and treatment course in children and adults. Arthritis Care & Research, 65(12), 1986-1990. doi:10. 1002/acr. 22086 Gerber, M. A., Shapiro, E. D., Burke, G. S., Parcells, V. J., & Bell, G. L., for the Pediatric Lyme Disease Study Group. (1996). Lyme disease in children in southeastern Connecticut. New England Journal of Medicine, 335(17), 1270. Kimberlin, D. W., Brady, M. T., Jackson, M., & Long, S. S. (2018). Red Book: 2018 report of the Committee on Infectious Diseases, American Academy of Pediatrics (31st ed. ). Itasca, IL: American Academy of Pediatrics. Reisen, W. K. (2010). Landscape epidemiology of vector‐borne disease. Annual Review of Entomology, 55, 461-483. pmid 193737082. Springer, Y. P., & Johnson, P. T. J. (2018). Large‐scale health disparities associated with Lyme disease and human monocytic ehrlichiosis in the United States, 2007-2013. PLo S ONE, 13(9), e0204609. https://doi. org/10. 1371/journal. pone. 0204609 Steere, A., Levin, R., Molloy, P., Kalish, R., Abraham, J., 3rd, Liu, N., & Schmid, C. (1994). Treatment of Lyme arthritis. Arthritis & Rheumatology, 37(6), 878. Thiers, B. (2006). Hematogenous dissemination in early Lyme disease. Yearbook of Dermatology and Dermatologic Surgery, 2006, 114. doi:10. 1016/s0093‐3619(08)70071‐6 Thompson, A., Mannix, R., & Bachur, R. (2009). Acute pediatric monoarticular arthritis: Distinguishing Lyme arthritis from other etiologies. Pediatrics, 123(3), 959-965. doi:10. 1542/peds. 2008‐1511 Wallendal, M. (1996). The discriminating value of serum lactate dehydrogenase levels in children with malig-nant neoplasms presenting as joint pain. Archives of Pediatrics & Adolescent Medicine, 150(1), 70. doi:10. 1001/ archpedi. 1996. 02170260074012 Wormser, G. P., Dattwyler, R. J., Shapiro, E. D., Halperin, J. J., Steere, A. C., Klempner, M. S., . . . Nadelman, R. B. (2006). The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplas-mosis, and babesiosis: Clinical practice guidelines by the Infectious Diseases Society of America. Clinical Infectious Diseases,43(9), 1089-1134. doi:10. 1086/508667
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403 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 6. 1 Preconception Planning RESOLUTION What health recommendations should be made for Delilah in order to help her prepar e for pregnancy? Delilah's BMI is 30. 5, which is considered obese. Obesity is associated with incr eased rates of infertility, along with a multitude of other chronic health conditions. Counseling on weight loss, healthy diet, and increasing physical activity levels would be appropriate. Smoking and alcohol use during pr egnancy are associated with a number of risks, including premature birth, spontaneous abortion (miscarriage), stillbirth, and intrauterine growth retar-dation. Smoking cessation counseling as well as counseling on reducing/eliminating alcohol consumption prior to trying to conceive is of utmost importance at this visit. Patients are often more motivated to discuss smoking and alcohol cessation when thinking about conceiving or becoming pregnant. Delilah's sleep habits are poor due to her work schedule; helping her find a way to develop a mor e regular sleep routine would be beneficial to her overall health. Additionally, limiting caf-feine intake is recommended when trying to conceive and during pregnancy. Ensuring that Delilah's asthma remains well contr olled prior to pregnancy is important; the use of inhaled steroids is not contraindicated during pregnancy. Due to her job, a detailed travel history should be obtained and risks associated with Zika exposure should be r eviewed. Depression and anxiety are common conditions in women of childbearing age and untreated depression during pregnancy is associated with poorer maternal and child outcomes. Screening for depression and anxiety during the preconception visit is recommended so, if necessary, treatment can be started and adjusted prior to conceiving. Assessing risk for sexually transmitted infections is also recommended. If any risk exists, STI scr eening should be completed. Screening for HIV is recommended in all pregnant women. Reviewing Delilah's immunization history and ensuring up‐to‐date vaccinations and/or evi-dence of immunity to tetanus, diphtheria, pertussis, varicella, measles, mumps, and rubella is an important part of preconception care.
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404 Resolutions What laboratory/diagnostic testing is recommended? HIV screening is recommended for all women planning pregnancy. Screening for tuberculosis (TB) may be recommended, depending on whether Delilah travels to regions with a high prevalence of TB. Delilah is due for her Pap smear, which can be completed today. Routine HPV screening is not recommended in women under the age of 30. Screening for diabetes with a fasting blood sugar or hemoglobin A1c is warranted based on her mother's history. How should Delilah's medication list be adjusted? Are any of the medications terato-genic? Are there any medications/vitamins or supplements she should start taking? None of Delilah's current prescription medications are teratogenic. It is important that she continue on her asthma controller medication to ensure adequate asthma control. Delilah should be counseled that when she is pregnant she should avoid products containing ibuprofen; acetamino-phen‐based products are fine. She does not have to change this until she is actively trying to become pregnant. In preparation for pregnancy it is recommended that Delilah start taking a daily folic acid sup-plement to help prevent neural tube defects. A supplement with 0. 4 mg of folic acid per day is ade-quate for most women. A daily prenatal vitamin would also be recommended. The folic acid requirement is often found within the prenatal vitamin. When should she stop her birth control pills? Oral contraceptive (birth control) pills are considered an immediately reversible form of contracep-tion. Therefore, it is possible for Delilah to become pregnant immediately after stopping the pill. If she and her husband would like to conceive in 6 months, it would be recommended that she remain on her birth control pill until that time. How should she be counseled about seeing a fertility specialist? When would this be recommended? The risk of infertility increases with age. In women under the age of 35, evaluation by a fertility specialist is not recommended until they have been actively trying to conceive for 12 months. Would anything be different if Delilah were 38 instead of 28? Once over the age of 35, evaluation with a fertility specialist is recommended after 6 months of actively trying to conceive. REFERENCES AND RESOURCES Frieder, A., Dunlop, A. L., Culpepper, L., & Bernstein, P. S. (2008). The clinical content of preconception care: Women with psychiatric conditions. American Journal of Obstetrics and Gynecology, 199(6), S328-S332. Moos, M. K., Dunlop, A. L., Jack, B. W., Nelson, L., Coonrod, D. V., Long, R., . . . Gardiner, P. M. (2008). Healthier women, healthier reproductive outcomes: Recommendations for the routine care of all women of reproductive age. American Journal of Obstetrics and Gynecology, 199(6 Suppl. 2), S280-S289.
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405 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 6. 2 Bleeding in the First Trimester of Pregnancy RESOLUTION What is the most likely differential diagnosis in this case? Spontaneous inevitable abortion. Which diagnostic tests are required in this case and why? CBC with differential: A CBC with differential is necessary to determine baseline level and/or need for emergent consultation if there is a significant hemorrhage or to rule out rupture of an ectopic pregnancy. Blood type with Rhesus type and antibody screen: Blood type with Rhesus type and antibody screen may be considered for this patient. Although not diagnostic, many patients have Rh sensitization as the reason for recurrent spontaneous abortions. Beta h CG: Beta h CG is a necessary test for this patient to determine if Tasha is pregnant. One of the first considerations is to determine if the vaginal bleeding is due to an obstetrical nonobstetrical cause. A beta h CG will help confirm a diagnosis of miscarriage and is required for management of this patient in determining baseline data and trending data with serial beta h CG testing for follow‐up. Normal beta h CG levels double every 1-2 days in early pregnancy; slow‐rising levels or lower‐than‐expected levels help confirm a diagnosis of spontaneous miscarriage. Progesterone level: A progesterone level can help confirm the diagnosis of a miscarriage. Values less than 5 ng/ml indicate abnormal or nonviable pregnancy. Doppler fetal heart tones: Heart tones can be considered in a fetus that is 10 weeks gestational age or greater and can confirm a pregnancy if fetal heart tones are heard. In this patient, who is having a miscarriage, fetal heart tones cannot be heard so this is not useful as a diagnostic tool. Transvaginal ultrasound: A transvaginal ultrasound is warranted in this case to help determine the diagnosis and will guide the management of this patient. A transvaginal ultrasound will determine if there is an intrauterine versus extrauterine pregnancy, can confirm fetal heartbeats (which is diag-nostic), and can provide an estimated due date and gestational age. In addition, a diagnosis can be made regarding the type of spontaneous abortion: complete, threatened, missed, or incomplete. Abdominal ultrasound: An abdominal ultrasound is often a useful diagnostic tool; however, in early pregnancy, the products of conception are frequently located in the uterus, which is tucked behind the symphysis pubis, making it difficult to fully complete an abdominal ultrasound. In pregnancy, abdominal ultrasounds are most useful in the second and third trimesters.
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406 Resolutions What are the concerns at this point? The patient presents with excessive vaginal bleeding so the primary concern should be of an acute hemorrhage and ectopic pregnancy. After the emergency evaluation, the focus should be on diag-nosing a spontaneous inevitable abortion. What is the plan of treatment? An inevitable abortion will require management to ensure complete evacuation of the products of conception. Most women will spontaneously pass the products of conception and expectant management is an acceptable treatment. Expectant management is a recommended treatment if the pregnancy is less than 12 weeks gesta-tional age, the patient is hemodynamically stable, and there are no signs of infection. Expectant management allows the patient to continue and naturally pass products of conception outside the clinical/hospital setting. Patients should be educated to monitor for excessive bleeding or saturation of a sanitary pad every hour or more frequently. They should monitor for fever and report fevers greater than 100. 4°F to the health care provider. Pain and cramping are normal expectations, especially during the passing of tissues. The patient can take over‐the‐counter ibuprofen 600 mg every 6 hours. If expectant management is unsuccessful after 4 weeks, then medical or surgical management is recommended. Surgical evacuation should be performed on patients who are hemodynamically unstable or have additional complications. The treatment plan should include surgical evacuation. Surgical evacuation is done with dilatation and curettage (D&C). Surgical management has been shown to have high success rates for evacuation of the products of conception; however, there are increased risks to surgical procedures What are the plans for follow‐up care? Beta h CG testing: Beta h CG levels should return to normal within 2-6 weeks after the evacuation of the products of conception. For patients who have had expectant management or medical management, weekly h CG levels should be drawn until the level is undetected. Counseling: Many patients may require counseling after a spontaneous abortion. Regardless of whether the pregnancy was planned or unplanned, many patients will grieve for the loss and may need some support. Family planning: Talk with the patient regarding the need for family planning and the need for safe sexual practices while in the perimenopausal state. The perimenopausal period can last a few years, dur-ing which the patient can become pregnant. Contraception should begin as soon as the abortion is complete. Are there any standardized guidelines that should be used to treat this case? If so, what are they? The American College of Emergency Medicine has a clinical policy on the evaluation and management of patient in early pregnancy (https://www. sciencedirect. com/sdfe/pdf/download/eid/1‐s2. 0‐S0196064412004064/first‐page‐pdf). The American College of Obstetricians and Gynecologist has a practice bulletin on the management of spontaneous abortions (https://www. acog. org/Clinical‐Guidance‐and‐Publications/Practice‐Bulletins/Committee‐on‐Practice‐Bulletins‐Gynecology/Early‐Pregnancy‐Loss). REFERENCES AND RESOURCES American College of Obstetricians and Gynecologists. (2015). Practice bulletin number 100: Early pregnancy loss. Obstetrics and Gynecology, 125(5), 1258. https://www. acog. org/Clinical‐Guidance‐and‐Publications/ Practice‐Bulletins/Committee‐on‐Practice‐Bulletins‐Gynecology/Early‐Pregnancy‐Loss Hahn, S. A., Lavonas, E. J., Mace, S. E., Napoli, A. M., & Fesmire, F. M. (2012). Clinical policy: Critical issues in the initial evaluation and management of patients presenting to the emergency department in early preg-nancy. Annals of Emergency Medicine, 60(3), 381-390. King, T. L., Brucker, M. C., Kriebs, J. M., & Fahey, J. O. (2013). Varney's midwifery (5th ed. ). Jones & Bartlett.
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407 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 6. 3 Night Sweats RESOLUTION What are the top three differential diagnoses to consider for Susan and why? Menopause‐related symptoms: Susan is experiencing several of the most common symptoms (e. g., hot flashes, night sweats, sleep disturbances, weight gain, altered sexual function) related to menopause transition as well as sev-eral associated symptoms (e. g., altered mood, hair thinning, memory changes) (see Table 6. 3. 1) (Alexander, Jakubisin Konicki, Barandouzi, et al., in press; Baber, Panay & Fenton, 2016; North American Menopause Society [NAMS], 2014). This diagnosis is usually made based on the history and physical examination. Selected diagnostic studies may be warranted to rule out comorbid con-ditions that may affect Susan's symptom severity and the management plan (Alexander, Jakubisin Konicki, Barandouzi, et al., in press; Baber et al., 2016; NAMS, 2014). Endocrine disorder: An endocrine disorder, especially hypothyroidism, must also be considered. Hypothyroidism has many common presenting symptoms that overlap with symptoms of the menopause transition (North American Menopause Society [NAMS], 2014). For example, Susan has described hair loss, fatigue, reduced libido, weight gain, irritability, memory loss, altered menstrual cycles, and reduced libido. These symptoms are all associated with both menopause and hypothyroidism (Garber et al., 2012; NAMS, 2014). She has not described cold temperature intolerance, weakness, constipation, hair texture changes, skin texture changes (dry and rough), or muscle aches, which are other symptoms associated with hypothyroidism (Garber et al., 2012). Additionally, she has described symptoms that are not com-monly associated with hypothyroidism but that are commonly associated with the transition to post‐menopause, such as hot flashes, night sweats, and sleep disturbances (Alexander et al., in press; NAMS, 2014). Given the overlap in symptoms and the potential for untreated hypothyroidism to exac-erbate symptoms of the transition to post‐menopause, it would be prudent to check Susan's TSH level. Like hypothyroidism, a sexual desire disorder is an important comorbid diagnosis to consider for Susan. Reduced libido is common among midlife women; however, a specific sexual desire disorder can also be present. The management of these 2 problems differs, so it is important to distinguish exactly what Susan is experiencing. The most common sexual desire disorder among women is female sexual interest/arousal disorder, formerly known as hypoactive sexual desire disorder, which affects approximately 43% of women (American College of Obstetrics and Gynecology [ACOG],
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408 Resolutions 2019; Shifren, Monz, Russo, Segreti & Johannes, 2008). Female sexual interest and arousal disorder is a lack of or decrease in at least three areas involving sexual activity interest, thoughts, responsiveness, excitement or pleasure, arousal, or sensations associated with sexual activity for a minimum of 6 months that has resulted in personal distress. This diagnosis is only met when there is no other non-sexual disorder to explain the symptoms (ACOG, 2019). While Susan described missing her previous level of desire for sex, she does enjoy sex when it happens; and she does not describe significant dis-tress, noting that it is a “bummer” and that she misses wanting sex like she used to. It is also unlikely that Susan is experiencing female sexual interest and arousal disorder as she does not avoid sexual contact with her partner; conversely, she has noted that she misses their usual level of sexual activity. Depression: Depression is less likely for Susan due to the array of symptoms that she is not experiencing and that are required to make a diagnosis of depression. The 5th edition of the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM‐5) specifies criteria for the diagnosis of depression (American Psychiatric Association [APA], 2013). DSM‐5 states that patients must experience symptoms for at least 2 weeks, including a change in functioning with either depressed mood or a loss of interest in things that they used to enjoy. Additionally, there must be at least 7 other symptoms, which can include depressed mood or loss of interest in enjoyable activ-ities/anhedonia, as well as substantive appetite and weight changes, sleep disturbances, suicidal thoughts or ideation, feeling worthless or excessively guilty, fatigue, cognitive changes (forgetful-ness, difficulty concentrating), or psychomotor changes (retardation or agitation) (APA, 2013). When considering depression it is important to note that Susan does not describe enough symp-toms to meet the DSM‐5 criteria for depression. However, it is also important to recognize that depression often does affect women at midlife and may exacerbate symptoms of the menopause transition (Green, Key, & Mc Cabe, 2015; Natari, Clavarino, Mc Guire, Dingle, & Hollingworth, 2018; NAMS, 2014; Weber, Maki, & Mc Dermott, 2014). Other: Other even less likely differentials might include TB, untreated DM or HTN, and other psychiatric disorders. None of these diagnoses carry enough overlapping symptoms with those described by Susan and commonly associated with the transition to post‐menopause to make them likely as her primary diagnosis. DM and HTN could exacerbate her menopause‐related symptoms. However, she does not have an elevated BP on examination, and she does not have symptoms suggestive of DM. TB is the least likely of all because the only overlapping symptom is night sweats. Table 6. 3. 1. Symptoms Associated with the Menopause Transition. System Symptoms Central nervous system Anxiety/nervousness, cognitive changes, depression, dizziness, fatigue, forgetfulness, formication, headache, hot flashes/flushes, insomnia, irritability/ mood disturbances/“rage,” night sweats, poor concentration, sleep disturbances, paresthesia Eyes Dry eyes Cardiovascular Palpitations Breast Mastalgia Gynecologic and sexual Dyspareunia, irregular menstrual bleeding, recurrent vaginitis, reduced libido, vaginal atrophy, vaginal dryness, vaginal/vulvar irritation, vaginal/vulvar pruritus Musculoskeletal Arthralgia, asthenia, myalgia Urinary Dysuria, genitourinary burning, recurrent cystitis, nocturia, stress urinary incontinence *, urinary frequency, urinary urgency Skin and hair Acne, dry skin and hair, hirsutism/virilization, skin dryness/atrophy, thinning hair, odor (increased perspiration) *Data are inconclusive. Source: From: Alexander et al. (in press); Baber et al. (2016); North American Menopause Society [NAMS] (2014).
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Night Sweats 409 Which diagnostic tests are required for managing Susan's condition and why? Diagnostic testing is not needed to diagnose the menopause transition except for ruling out comor-bid conditions or identifying medical problems that may exacerbate the woman's menopause transition symptoms and thus affect the plan of care. 1. FSH, estrogen, and LH levels: Hormone levels are not tested to determine menopausal status (NAMS, 2014). Hormone levels are very volatile during the perimenopausal years, rendering testing at any one point in time useless (NAMS, 2014). The goal of treatment is symptom management, and hormone levels are not used to monitor efficacy. Thus knowledge of specific hormone levels is unnecessary. Additionally, if hormone levels are tested, the information may falsely suggest that the woman is postmenopausal when she is actually perimenopausal and could still ovulate and become pregnant. 2. TSH level: T esting TSH may be useful to determine if Susan also has a thyroid problem. It will not aid in diagnosing the menopause transition but may guide care, as an untreated thyroid disorder can exacerbate symptoms of the menopause transition. 3. Fasting lipid panel and fasting blood sugar level: While it may be r easonable to order a fasting lipid panel for Susan if she has not had one recently, it will not forward the diagnosis of her symptoms. Testing a fasting blood sugar level may be useful in identifying if Susan also has DM. This also will not aid in diagnosing the menopause transition but may guide care, as untreated DM can exacerbate symptoms of the menopause transition and may alter the selec-tion of pharmacotherapeutics. 4. CBC, BUN/creatinine, e GFR: These tests are not needed for diagnosing the menopause transition. Knowing Susan's kidney function status may be useful when determining whether to use pharmacotherapeutics to manage her symptoms. 5. LFTs: These tests are not needed for diagnosing the menopause transition. Knowing Susan's liver function status may be useful when determining whether to use pharmacotherapeutics to manage her symptoms. 6. Beck Depression Inventory (BDI): Administering the BDI may be useful to determine if Susan also has depression. It will not aid in diagnosing the menopause transition, but it may guide care, as untreated depression can exacerbate menopause transition symptoms and may alter the selection of pharmacotherapeutics. 7. PPD/Quantiferon gold: If Susan had a history suggesting exposure to TB, it would be prudent to check PPD or quantiferon gold because she is experiencing night sweats. However, most of her history suggests an alternate diagnosis; for example, she is gaining, rather than losing weight and she has no cough or other symptoms suggestive of TB. Thus, it is unlikely that testing for TB will provide useful clinical information. 8. DXA: It is too early to or der a routine DXA for Susan (Cosman et al., 2014). Guidelines recom-mend evaluating all postmenopausal women at age 65 unless they have specific additional risk factors (Cosman et al., 2014). DXA test results will not aid in the diagnosis of her symptoms. 9. Colonoscopy: The American Cancer Society recommends that all adults receive colon cancer screening at age 50 or earlier depending on personal history (Wolf et al., 2018). Colonoscopy, however, will not aid in the diagnosis of her symptoms. What are the concerns at this point? Susan has a history of gestational hypertension with her second pregnancy. There is a twofold risk for the development of cardiovascular disease in women with a history of hypertensive disorders of pregnancy (HDP) (Timpka et al., 2018). Susan will benefit from lifestyle measures that focus on promotion of heart‐ healthy behaviors and monitoring for cardiovascular disease. What is the plan of treatment options to be discussed with Susan? Most of Susan's symptoms are related to her hot flashes. Vasomotor symptoms cause sleep disrup-tions, which in turn affect mood, energy level, memory, and cognitive processes. Once the hot
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410 Resolutions flashes are controlled and sleep is restored, the associated symptoms usually will resolve (NAMS, 2007). A stepped approach is recommended for managing vasomotor symptoms associated with the menopause transition (Alexander et al., in press; Daley, Stokes‐Lampard, Thomas, & Mac Arthur, 2014). Start by advising Susan about lifestyle and environmental changes that can reduce her symp-toms, then explore complementary and alternative medicine therapies (CAM) that might help her, and, finally, prescribe medications if needed. Susan likely would benefit from increasing her routine aerobic activity. Her goal should be at least 1 hour each day, but even small increases may be beneficial (Baber et al., 2016; NAMS, 2014). Aerobic exercise helps to decrease hot flash severity and frequency by improving the body's ability to maintain temperature regulation (Thompson, Church, & Blair, 2008). Regular exercise also improves sleep quality, memory, and quality of life; decreases depression; reduces cardiac disease risk; and helps to maintain normal blood glucose levels and weight in midlife women (Thompson et al., 2008). Susan also needs to be counseled to avoid hot flash triggers such as caffeine (any type —cold, hot, solid, liquid—can trigger flashes), concentrated sugar, alcohol, and food additives such as sodium nitrates, sulfites, and monosodium gluconate. Reducing or avoiding use of these sub-stances can reduce both frequency and severity of her vasomotor symptoms (NAMS, 2014). Increasing her consumption of ice water may help to stabilize her core temperature and reduce hot flashes (ACOG, 2016). Susan can further reduce her symptoms by wearing breathable fabrics like cottons that allow for greater air movement and avoiding synthetics and tight clothing. Wearing layers that can easily be removed when she feels hot and avoiding high necklines and turtleneck shirts may reduce her symptoms and embarrassment at work. Using breathable fabrics for her pajamas, sheets, and blan-kets is important as well. Using a fan to circulate the air and keeping the room temperature at a moderately cool level may also reduce hot flashes (Alexander et al., in press; NAMS, 2014). Several CAM therapies such as relaxation and deep breathing exercises, acupuncture, and selected botanical or herbal preparations may be useful in reducing vasomotor symptoms caused by the menopause transition. Stress and anxiety are triggers for hot flashes (Alexander et al., 2004), so it stands to reason that relaxation and stress‐reducing practices, like yoga, prayer, and talking over problems, can decrease hot flashes (NAMS, 2014). Susan can be taught to do paced deep breathing (like yoga breathing: breathe in deeply over a count of 5, hold the breath for a count of 7, then exhale over a count of 9) to reduce hot flashes when they occur or to reduce her stress in gen-eral (Freedman & Woodward, 1992; Freedman, Woodward, Brown, Javaid, & Pandy, 1995). Acupuncture is another CAM therapy that provides stress relief. Evidence suggests that there are some beneficial effects of acupuncture in the treatment of menopause‐related symptoms of sleep disorders and vasomotor symptoms (Befus et al., 2018; Chiu et al., 2015; NAMS, 2014; Nedeljkovic et al., 2014). Susan could try acupuncture if she is interested; it is a well‐accepted and safe practice that promotes relaxation. Many women are interested in trying botanical and herbal preparations to manage their meno-pause transition symptoms. Several preparations are commonly used, including black cohosh, dong quai, various isoflavones (i. e., soy extracts, red clover, soy supplementation), oil of evening primrose, and ginseng (Ahsan & Mallick, 2017; Messina, 2014). Black cohosh is usually well toler-ated and has the most evidence supporting its use. It may have some estrogenic activity (NAMS, 2014), so if Susan decides to try this she will need to be monitored for endometrial overgrowth. She also needs to be warned to watch for signs of liver problems, as case reports have identified hepatitis and liver toxicity in some women (Mahady et al., 2008). Pharmacotherapeutics: Both nonhormonal and hormonal prescription options are available to help Susan if she is still experiencing moderate to severe symptoms (see Table 6. 3. 2). Many women wish to avoid the use of hormones, so Susan needs to be carefully questioned about her specific prefer-ences. Additionally, because every medication has contraindications, Susan's medical, family, and personal history must be carefully reviewed to assure that any specific medication being considered
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Table 6. 3. 2. Prescription Options* for Managing Vasomotor Symptoms Associated with Menopause T ransition. Medication Class Example(s) General Cautions and Contraindications Comments Anticonvulsants Gabapentin (Neurontin) Do not take within 2 hours of antacids. CNS depression potentiated by alcohol. Avoid discontinuing abruptly. Titrate dose up slowly to reduce somnolence. Anti‐hypertensives Bellergal Clonidine Methyldopa Tricyclic antidepressants antagonize clonidine. CNS depressants are potentiated by clonidine. Clonidine is available as a patch. SSRIs/SNRIs and gabapentin have higher efficacy than clonidine. Avoid abruptly discontinuing clonidine. Bellergal and methyldopa are not recommended because of toxicity. Breast cancer agent (progestin)Megestrol (Megace) Use caution in patients with diabetes or a history of a thromboembolic disorder. May increase requirements for insulin. Selective serotonin reuptake inhibitors (SSRIs)/ serotonin norepinephrine reuptake inhibitors (SNRIs)Desvenlafaxine (Pristiq)Fluoxetine (Prozac)Paroxetine (Paxil, Paxil CR)Venlafaxine (Effexor XR)Avoid use with thioridazine or monoamine oxidase inhibitors. Use caution in patients taking warfarin. Warn patients to avoid using with alcohol. Use caution in patients with diabetes, diseases that alter metabolism, and heart disease. Avoid discontinuing abruptly. Monitor weight regularly (fluoxetine). Estrogen** Conjugated estrogens and conjugated estrogens, B (Cenestin, Enjuvia, Premarin) Estradiol (Alora, Climara, Divigel, Elestrin, Esclim, Estraderm, Estrasorb, Estro‐Gel, Evamist, Menostar, Vivelle, Vivelle‐Dot) Estradiol acetate (Femtrace, Femring) Estradiol hemihydrate (Vagifem) Esterified estrogens (Menest)Estropipate (Ogen, Ortho‐est)Micronized estradiol (Estrace, Estring)Do not use in patients with unexplained vaginal bleeding. Do not use in patients with cardiovascular disease, liver disease, breast cancer, estrogen‐dependent cancer, pregnancy, or thromboembolism. Available in multiple delivery forms: oral pill; transdermal patch, mousse, cream, gel, spray; injectable; vaginal cream, tablet, ring. Also available in combination with progestogens or methyltestosterone in varied forms. Use the lowest dose that controls symptoms for the shortest period of time possible. Wean off with slowly decreasing doses. *Consult a prescribing reference to obtain complete information regarding doses, cautions, contraindications, and side effects. The use of nonhormonal medications to manage vasomotor symptoms associated with the menopause transition is off label. Nonhormonal medications are less effective than estrogen for managing vasomotor symptoms. **Progestogen is used to prevent endometrial hyperplasia and endometrial cancer for any woman who is taking estrogen and has her uterus. Source: Alexander et al. (in press); North American Menopause Society [NAMS] (2014, 2018); Ahsan and Mallick (2017); Messina (2014); e Pocrates. Computerized pharmacology and prescribing reference. Updated daily. Available at: www. epocrates. com (accessed August 29, 2019). Night Sweats 411
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412 Resolutions is an appropriate option for her. Similarly, common side effects from specific medications must be reviewed to determine if they would help or further increase any of Susan's symptoms. For example, selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) are known to commonly cause sexual disturbances and anorgasmia. In Susan's case it may be prudent to avoid use of this class of medication since she is already experiencing vaginal dryness, reduced libido, and increased time to orgasm. Systemic estrogen therapy will reduce hot flash fre-quency and severity as well as improve vaginal dryness, among a number of other symptoms. This medication option is reasonable for Susan as she has none of the contraindications that might pre-clude its use (e. g., no breast cancer, no unexplained bleeding, no heart disease, no inherited or personal history of thromboembolic disease). Hormone therapy (HT) is the most effective agent for managing vasomotor symptoms as well as multiple other symptoms associated with the menopause transition (Baber et al., 2016; NAMS, 2015, 2018). For a woman with her uterus in place, such as Susan, estrogen is taken daily and progesterone is either taken daily to impede endometrial lining buildup or monthly to cause sloughing of the endo-metrial lining resulting in a withdrawal of bleed. Progesterone is used to prevent the development of endometrial hyperplasia and endometrial cancer (Baber et al., 2016; NAMS, 2015, 2018). The combined data from multiple studies, including the Women's Health Initiative (WHI), have indicated that HT is safe for women less than 60 years of age and within 10 years of menopause to take for 3-5 years when initiated around the time of transition to postmenopause (NAMS, 2018). After 3-5 years of use the risks for developing breast cancer and heart disease may increase. Indeed, most national and international organizations recommend the use of HT for managing symptoms associated with the menopause transition at the lowest dose that effectively controls symptoms and for the shortest time period possible. Women should have regular health screenings, such as mammograms and blood pressure measurements, while taking HT. What are the recommendations for referral and follow‐up care? Referrals are not likely to be needed for Susan unless her symptoms are resistant to usual management options. If this occurs, then referral to a menopause specialist is warranted. A gynecologic exam is not required to initiate HT. Routine follow‐up is important with annual bimanual exams, clinical breast exams, and mammography. Follow‐up specific to initiating HT or another medication for symptom management is intended to monitor efficacy while also identi-fying early any untoward side effects or sequelae. HT takes up to 6 weeks to reach full efficacy. Thus an appointment around 6 weeks after initiation is reasonable to determine whether the initial dose is appropriate and effective and to evaluate for bleeding, increased blood pressure, or other side effects. The North American Menopause Society (2018) recommends starting at a low dose and increasing using small increments if symptom management is not achieved. Once symptoms are stabilized, annual reevaluation of the need for therapy and the present dose is recommended (NAMS, 2018). For Susan, a return appointment at about 6 weeks and again at 1 year is appropriate if she is not having concerning side effects and if her symptoms are manageable. At 1 year it might be reasonable to try skipping some days of therapy or reducing the dose even further to see if her symptoms increase or if she is tolerant to a small increase in symptoms. If not, then return to the prior dose; and if so, then consider reducing the dose further or remain at the lowered dose and reassess in another year. If Susan's symptoms are not well controlled, or if her libido does not respond to estrogen plus progestin therapy despite an adequate dose, it may be reasonable to add methyltestosterone. Although off‐ label for sexual benefit, this treatment is approved for women who have resistant vasomotor symptoms and has been shown to improve libido and sexual experiences for women (NAMS, 2018). What health education should be provided for Susan? Susan needs to be counseled about sexual health and vaginal dryness. HT can take up to 6 weeks to become effective and SSRIs/SNRIs will not help with vaginal dryness. Susan may need to use
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vaginal lubricants or vaginal estrogen therapy either until the full effect of systemic HT is realized or for the duration of therapy with SSRI/SNRIs and beyond. In addition, Susan needs to have counseling about midlife health risks such as osteoporosis and heart disease. If she takes HT it will help protect her from bone loss. She will also need to ensure that she is getting an adequate daily intake of calcium (1200-1500 mg) and vitamin D (800-1000 IU); has regular exercise that includes aerobic, resistive, and weight‐ bearing activities; avoids smoking or excessive use of alcohol or caffeine; and has regular DXA screening tests when appro-priate. If she elects to use a nonhormonal medication or when she stops taking the HT she may also require medication to prevent or treat osteoporosis. Regular exercise will also help her to prevent heart disease. Given her history of HDP she has an increase risk for heart disease. This risk further increases dramatically after menopause and may even exceed the risks carried by men. Susan needs to have regular lipid panel screening tests, follow a heart‐ healthy diet, and maintain a normal weight to identify problems early and keep her risk factors as low as possible. What if Susan also had diabetes or hypertension? If Susan had diabetes or hypertension a transdermal delivery method for HT might be preferable to oral. This is because oral HT can alter blood sugar levels and is processed in the liver with a first‐ pass effect. These combined effects can create medication interactions that potentially interfere with diabetes and hypertension management. These effects are reduced with transdermal therapy. There is little to no liver first‐ pass effect with transdermal therapy; and since the delivery is via the skin, hormone levels may be steadier, possibly reducing the effects on glucose levels. What if Susan were over age 65? The WHI study evaluated the use of HT, either estrogen plus progesterone or estrogen alone; the estrogen plus protesterone portion of the study terminated early due to a concern that the risks of use outweighed the benefits. Subanalyses of the WHI and new data from the past 10 years demon-strated that there is an important effect related to when HT is started. There is variability by both age and time since menopause of HRT on organ systems (Baber et al., 2016). The risks seen in the larger study were not present in younger women (< 60 years of age) when the data were analyzed according to 10‐year aged cohorts (i. e., 50-59, 60-69, 70-79) (Chlebowski et al., 2009; Hsia et al., 2006; Rossouw et al., 2007). Thus, if Susan were 65 or greater than 10 years from menopause and presented with similar symptoms, HT would not be a great option for her. Instead, Susan might do better with gabapentin or one of the SSRIs/SNRIs, despite the possible sexual side effects. Does Susan's psychosocial history affect the management recommendations? Several aspects of Susan's psychosocial history can be important when developing a management plan with her. If Susan had depression in addition to experiencing symptoms associated with the menopause transition, she might benefit from the use of an antidepressant agent, despite the pos-sible risks for reduced sexual functioning. Consideration of Susan's insurance medication coverage is also important when selecting an agent. Several generic medications are available among both the hormonal and nonhormonal prescription options. This is taken into account when prescribing an agent for Susan so that the cost of therapy does not become a barrier to her ability to use the therapy she has selected. Additionally, Susan's preference for prescription therapy versus CAM therapy is important. If Susan does not think HT is safe, then she may have increased anxiety if she uses it, or she might take the prescription and never fill it. An open discussion that provides her with ample opportunity to share her concerns and considerations and that provides factual information including both benefits and risks is needed to individualize therapy for Susan and develop an acceptable and beneficial management plan. Are there any standardized guidelines that should be used when developing a management plan with Susan? If so, what are they? The combined data from multiple studies, including the WHI study, suggest that HT is safe for healthy women to take for at least 5 years when initiated before the age of 60 (Baber et al., 2016; Night Sweats 413
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414 Resolutions Hsia et al., 2006; NAMS, 2014, 2018; Rossouw et al., 2007). Further, the research indicates that combined HT started in those < 60 years of age early in this window of opportunity may confer some cardioprotection (Baber et al., 2016). After 5 years of use, the individual risk profile of the woman must be evaluated, as the risks for developing breast cancer and heart disease may increase. Thus, most national organizations and the US Food and Drug Administration recommend the use of HT only for managing symptoms associated with menopause at the lowest dose that effectively controls symptoms and for the shortest time possible (Baber et al., 2016; NAMS, 2014, 2018). Regular health screenings are also recommended while any woman is taking HT, so Susan should be counseled to have an annual mammogram, regular blood pressure screenings, and to report any signs or symptoms of heart disease or any breast changes. REFERENCES AND RESOURCES Ahsan, M., & Mallick, A. K. (2017). The effect of soy isoflavones on the menopause rating scale scoring in peri-menopausal and postmenopausal women: A pilot study. Journal of Clinical and Diagnostic Research: JCDR, 11(9), FC13. Alexander, I. M., Jakubisin Konicki, A., Barandouzi, Z. A., et al. (in press). Chapter 14: Menopause. In F. Likis & K. Schuiling (Eds. ), Women's gynecologic health (4th ed. ). Sudbury, MA: Jones & Bartlett Learning. Alexander, I. M., Ruff, C., Rousseau, M. E., White, K., Motter, S., Mc Kie, C., & Clarke, P. (2004, August). Experiences and perceptions of menopause and midlife health and self‐management strategies identified by black women. Department of Health and Human Services (DHHS) Conference: Women of Color Taking Action for a Healthier Life: Progress, Partnerships and Possibilities, Washington, DC. American College of Obstetrics and Gynecology. (2016). Practice bulletin no. 141: Management of menopausal symptoms: Correction. Obstetrics & Gynecology, 127(1), 166. doi:10. 1097/AOG. 0000000000001230 American College of Obstetrics & Gynecology. (2019). Practice bulletin clinical management guidelines for obstetrician-gynecologists, number 213: Female sexual dysfunction. Obstetrics & Gynecology, 134(1), e1-e18. doi:10. 1097/AOG. 0000000000003324 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed. ). Washington, DC: American Psychiatric Association. Baber, R. J., Panay, N., & Fenton, A. (2016). 2016 IMS recommendations on women's midlife health and men-opause hormone therapy. Climacteric, 19(2), 109-150. doi:10. 3109/13697137. 2015. 1129166. Befus, D., Coeytaux, R. R., Goldstein, K. M., Mc Duffie, J. R., Shepherd‐Banigan, M., Goode, A. P., . . . Williams, J. W. Jr. (2018). Management of menopause symptoms with acupuncture: An umbrella systematic review and meta‐analysis. Journal of Alternative and Complementary Medicine, 24(4), 314. doi:10. 1089/acm. 2016. 0408 Chiu, H. Y., Pan, C. H., Shyu, Y. K., Han, B. C., & Tsai, P. S. (2015). Effects of acupuncture on menopause‐related symptoms and quality of life in women in natural menopause: A meta‐analysis of randomized controlled trials. Menopause, 22(2), 234-244. Chlebowski, R. T., Kuller, L. H., Prentice, R. L., Stefanick, M. L., Manson, J. E., Gass, M., . . . Anderson, G., for the WHI Investigators. (2009). Breast cancer after use of estrogen plus progestin in postmenopausal women. New England Journal of Medicine, 360(6), 573-587. Cosman, F., de Beur, S. J., Le Boff, M. S., Lewiecki, E. M., Tanner, B., Randall, S., & Lindsay, R. (2014). Clinician's guide to prevention and treatment of osteoporosis. Osteoporosis International, Online (August 2014), 1-25. Accessed July 30, 2019. Available at file:///C:/Users/ima00001/Downloads/Clinicians‐Guide. pdf Daley, A., Stokes‐Lampard, H., Thomas, A., & Mac Arthur, C. (2014). Exercise for vasomotor symptoms. Cochrane Database of Systematic Reviews, 11, CD006108. doi:10. 1002/14651858. CD006108. pub4 Freedman, R. R., & Woodward, S. (1992). Behavioral treatment of menopausal hot flashes: Evaluation by ambulatory monitoring. American Journal of Obstetrics and Gynecology, 167, 436-439. Freedman, R. R., Woodward, S., Brown, B., Javaid, J. I., & Pandy, G. N. (1995). Biochemical and thermoregula-tory effects of treatment for menopausal hot flashes. Menopause, 2, 211-218. Garber, J. R., Cobin, R. H., Gharib, H., Hennessey, J. V., Klein, I., Mechanick, J. I., . . . Woeber, K. A. (2012). Clinical practice guidelines for hypothyroidism in adults: Cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocrine Practice: Official Journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists, 18(6), 988. doi:10. 4158/EP12280. GL
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Green, S. M., Key, B. L., & Mc Cabe, R. E. (2015). Cognitive‐behavioral, behavioral, and mindfulness‐based therapies for menopausal depression: A review. Maturitas, 80(1), 37-47. Hsia, J., Langer, R. D., Manson, J. E., Kuller, L., Johnson, K. C., Hendrix, S. L., . . . Prentice, R., for the Women's Health Initiative Investigators. (2006). Conjugated equine estrogens and coronary heart disease: The Women's Health Initiative. Archives of Internal Medicine, 166(3), 357-365. Mahady, G. B., Low Dog, T., Barrett, M. L., Chavez, M. L., Gardiner, P., Ko, R., . . . Sarma, D. N. (2008). United States pharmacopeia review of the black cohosh case reports of hepatotoxicity. Menopause, 15(4 Pt 1), 628-638. Messina, M. (2014). Soy foods, isoflavones, and the health of postmenopausal women. American Journal of Clinical Nutrition, 100(Suppl 1), 423S-430S. Natari, R. B., Clavarino, A. M., Mc Guire, T. M., Dingle, K. D., & Hollingworth, S. A. (2018). The bidirectional relationship between vasomotor symptoms and depression across the menopausal transition: A systematic review of longitudinal studies. Menopause, 25(1), 109-120. Nedeljkovic, M., Tian, L., Ji, P., Déglon‐Fischer A., Stute P., Ocon E., . . . Ausfeld‐Hafter, B. (2014). Effects of acupuncture and Chinese herbal medicine (Zhi Mu 14) on hot flushes and quality of life in postmenopausal women: Results of a four‐arm randomized controlled pilot trial. Menopause, 21(1), 15-24. North American Menopause Society. (2014). Menopause practice: A clinician's guide (5th ed. ). Mayfield Heights, OH: North American Menopause Society. North American Menopause Society. (2018). The 2017 hormone therapy position statement of the North American Menopause Society. Menopause, 25(11), 1362-1387. doi:10. 1097/GME. 0000000000001241 Rossouw, J. E., Prentice, R. L., Manson, J. E., Wu, L., Barad, D., Barnabei, V. M., . . . Stefanick, M. L. (2007). Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. Journal of the American Medical Association, 297(13), 1465-1477. Shifren, L. J., Monz, U. B., Russo, A. P., Segreti, B. A., & Johannes, B. C. (2008). Sexual problems and distress in United States women: Prevalence and correlates. Obstetrics & Gynecology, 112(5), 970-978. doi:10. 1097/ AOG. 0b013e3181898cdb Timpka, S., Fraser, A., Schyman, T., Stuart, J. J., Åsvold, B. O., Mogren, I., . . . Rich‐Edwards, J. W. (2018). The value of pregnancy complication history for 10‐year cardiovascular disease risk prediction in middle‐aged women. European Journal of Epidemiology, 33(10), 1003-1010. Thompson, A. M., Church, T. S., & Blair, S. N. (2008, March 13). Effect of different doses of physical activity on quality of life in overweight, sedentary, postmenopausal women (presentation, abstract). Paper presented at the American Health Association Nutrition, Physical Activity and Metabolism Conference and 48th Annual Cardiovascular Disease Epidemiology and Prevention Conference, Colorado Springs, CO. Weber, M. T., Maki, P. M., & Mc Dermott, M. P. (2014). Cognition and mood in perimenopause: A systematic review and meta‐analysis. Journal of Steroid Biochemistry and Molecular Biology, 142, 90-98. Wolf, A. M. D., Fontham, E. T. H., Church, T. R., Flowers, C. R., Guerra, C. E., Lamonte, S. J., . . . Smith, R. A. (2018). Colorectal cancer screening for average‐risk adults: 2018 guideline update from the American can-cer society. CA: A Cancer Journal for Clinicians, 68(4), 250-281. doi:10. 3322/caac. 21457Night Sweats 415
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417 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 6. 4 Pelvic Pain RESOLUTION What is the most likely differential diagnosis in this case? Pelvic inflammatory disease (PID). Which diagnostic tests are required in this case and why? CBC: A CBC is not needed for the diagnosis of PID; however, a CBC would be useful to know if the white blood count is elevated. Nucleic acid amplification tests: NAAT testing should be done to test for Neisseria gonorrhea and Chlamydia trachomatis. Neisseria gonorrhea and Chlamydia trachomatis are the two most common sex-ually transmitted infections (STIs) associated with PID. A positive test supports the diagnosis of PID; however, a negative test does not rule out PID, as other bacteria can cause PID, such as anaer-obes, G. vaginalis, enteric Gram‐negative rods, and Streptococcus agalactiae. Beta h CG: Beta h CG is a necessary test for this patient to determine if she is pregnant and to rule out an ectopic pregnancy. HIV: HIV is not diagnostic for PID; however, this test should be included in the general management of a patient who presents with a history of multiple sex partners and recent sexually transmitted infections. Wet mount: A wet wound examination of vaginal secretions with saline may show an abundance of white blood cells and can help confirm the PID diagnosis. Treponema pallidum: Treponema pallidum is not diagnostic for PID; however, this test should be included in the general management of a patient who presents with a history of STIs to rule out other possible STIs. Transvaginal ultrasound: A transvaginal ultrasound can be performed to confirm the diagnosis. Imaging should be considered if there is concern about a tubo‐ovarian abscess. Imaging may dem-onstrate thickening and fluid‐filled Fallopian tubes. What is the plan of treatment? Outpatient treatment is an acceptable option for patients with mild to moderate PID, who tolerate oral antibiotics and can adhere to the prescribed course of therapy. Patients will require hospitaliza-tions if they have severe PID or complications such as pregnancy or tubo‐ovarian abscess, are unable to follow or tolerate oral medication, or fail to respond to outpatient treatment within 72 hours.
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418 Resolutions Oral Treatment IV Treatment Ceftriaxone 250 mg IM in a single dose Or Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose Or Another parenteral third‐generation cephalosporin PLUSDoxycycline 100 mg orally twice a day for 14 days(WITH or WITHOUT)Metronidazole 500 mg orally twice a day for 14 days Cefotetan 2 g IV every 12 hours Or Cefoxitin 2 g IV every 6 hours PLUSDoxycycline 100 mg orally or IV every 12 hours Source: Workowski and Bolan (2015). What are the plans for follow‐up care? For patients with outpatient treatment, follow‐up should occur within 48-72 hours to ensure effec-tive treatment and improvement of symptoms. If the patient is improving, they can continue with outpatient treatment; for patients with worsening symptoms or minimal improvement, hospitali-zation with intravenous therapy should be considered. Repeat testing for gonorrhea and chlamydia should occur within 3-6 months for patients with previously positive results. What health education should be provided to this patient? The patient should adhere to pelvic rest until therapy is completed and symptoms are resolved. Pelvic rest includes abstaining from vaginal intercourse and avoiding inserting anything into the vagina such as tampons or douching. Shanae should be taught safe sexual practices. Although Shanae is using oral contraception, she is still at risk for STIs. Shanae's male sexual partners should be treated for gonorrhea and chlamydia if they have had sexual intercourse with her within the past 60 days prior to her clinical symptoms. Shanea should abstain from sexual intercourse until her sexual partner has been treated. Are there any standardized guidelines that should be used to treat this case? If so, what are they? The Centers for Disease Control has detailed information on the treatment of PID (https://www. cdc. gov/mmwr/preview/mmwrhtml/rr6403a1. htm). REFERENCES AND RESOURCES Workowski, K. A., & Bolan, G. A. (2015). Sexually transmitted diseases treatment guidelines, 2015. Morbidity and Mortality Weekly Report. Recommendations and Reports, 64(RR‐03), 1. https://www. cdc. gov/mmwr/ preview/mmwrhtml/rr6403a1. htm
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419 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 6. 5 Vaginal Itching RESOLUTION Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? A wet mount, including KOH and whiff test, would be indicated. Martha's multiple partners warrant a check for sexually transmitted infections (STIs). Martha should be asked about these tests before they are done. The testing for STIs (gonorrhea and chlamydia) may be done via a urine sample or through cultures during the pelvic exam. Recurrent infections would warrant HIV test-ing. A urinalysis would be indicated to rule out signs of a urinary tract infection given her com-plaint of burning with urination. A Pap smear is not indicated, given that her last Pap smear was 2 years ago and was normal. If a wet mount were performed, what findings would be expected for the following diagnoses? See Table 6. 5. 1. What is the most likely differential diagnosis and why? See Table 6. 5. 2. Candidiasis The symptom of itching, the curd‐like white discharge, the burning with urination, and the dyspa-reunia support this diagnosis. The vaginal swelling also contributes to the diagnosis. Martha's recent antibiotic use increases her risk for this diagnosis. What is the plan of treatment? Both topical and oral treatment options are available. When deciding between topical and oral preparations clinicians should consider patient preference and cost, as well as the following: Topical agents ar e generally used for between 1 and 7 days depending on the formulation. They can provide more immediate relief due to their local action and many are available over the counter (OTC). However, topical agents can potentially cause local hypersensitivity reactions resulting in increased itching or burning.
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420 Resolutions T able 6. 5. 1. Wet Mount Findings. Diagnosis p H Saline Prep KOH Prep Bacterial vaginosis>4. 5 >20% clue cells + whiff test Candidiasis Normal (3. 8-4. 2)Possible visualization of hyphae/buds on saline prep, more visible on KOH prep Hyphae/pseudohyphae, buds or spores Negative whiff test Trichomonas >4. 5 Mobile protozoa with flagella, increased WBCs Sometimes + whiff (not always) Table 6. 5. 2. Differential Diagnosis. Condition Signs and Symptoms Trichomonas Foul‐smelling discharge, usually a fishy odor; vaginal burning sensation; possible postcoital bleeding; itching; dysuria, dyspareunia; may be asymptomatic. Bacterial vaginosis Fishy vaginal odor; thin white or gray discharge; postcoital burning; possible itching; may be asymptomatic. Chlamydia Possibly mucopurulent discharge; pelvic pain; dysuria, spotting, and altered menstruation; postcoital bleeding; may be asymptomatic. Male: Dysuria, cloudy and thick penile discharge; may be asymptomatic. Gonorrhea Asymptomatic early; leukorrhea; suprapubic pain, dysuria, dyspareunia, pharyngitis; labial pain and swelling. Later: purulent discharge, rectal pain and discharge; nausea, vomiting, fever; arthralgias and joint swelling; genital lesions and swelling. Male: Dysuria, pharyngitis, white penile discharge that progresses to yellow‐green, epididymitis, and proctitis; may be asymptomatic. Herpes genitalis First episode: Lesions; malaise, fever, dyspareunia, arthralgias and myalgias, fever, and lymphadenopathy. Recurrent episodes: Less symptomatic, usually have prodrome of itching, burning, or tingling. Urinary tract infection Dysuria, urinary frequency, urinary urgency, suprapubic pressure/discomfort, mild low back discomfort. Oral agents have convenient dosing (typically just 1 pill taken once) and are less messy and cumbersome than topical agents. However, they can have systemic side effects and interact with other medications. Topical agents: Butoconazole cream (pr escription) Ter conazole cream or suppositories (prescription) Clotrimazole cream (OTC) Miconazole cream or suppositories (OTC) Tioconazole ointment (OTC) First‐line oral agent: Fluconazole 150mg table ×1 What education should be provided to Martha at this visit? Instruction regarding how to avoid recurrent candida infections and how to avoid STIs will be paramount during the visit. Martha should avoid intercourse until her symptoms resolve. Important points to discuss around the prevention of future vaginal infections include: avoiding
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Vaginal Itching 421 douching, feminine deodorants, and heavily scented soaps or detergents; removing damp or wet clothing immediately (for instance, after swimming or exercise) and wearing loose, breath-able clothing when possible. Are any referrals needed? No referrals are needed unless Martha has an intractable case; she does not require follow‐up unless this infection is unresponsive. Is the family history of diabetes relevant to this case? Martha has a family history of diabetes mellitus, so it is worthwhile testing her for DM and moni-toring her for prediabetes. Vaginal candidiasis, especially frequent infections, can be a warning sign of diabetes. How can the clinician support the patient regarding her confusion with her sexual preferences? The clinician can work to develop a rapport with Martha and gain her trust so that Martha feels comfortable sharing her feelings. The clinician should avoid making assumptions or judgments, use neutral and inclusive terms/vocabulary, normalize any questions being asked (“I ask all of my patients these questions”), and provide factual information and resources. REFERENCES AND RESOURCES Hawkins, J. W., Roberto‐Nichols, D. M., & Stanley‐Haney, J. L. (2015). Guidelines for nurse practitioners in gynecologic settings (11th ed. ). New York: Springer. Paladine, H. L., & Desai, U. A. (2018). Vaginitis: Diagnosis and treatment. American Family Physician, 97(5), 321-329. NOTE: The author would like to thank Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN for her contribution to this case in the first edition of this book.
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423 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 6. 6 Redness and Swelling in the Breast RESOLUTION Which diagnostic tests should be considered? In a young symptomatic patient like Jill (pain, edema of the skin, and fluctuant mass), an ultra-sound of the breast should be the first investigative study. Young women have breast tissue that is much denser than in older women and this can make it harder to detect an abnormality using mammography. Ultrasound is a noninvasive way of determining if a mass is solid or fluid filled and if aspiration of the fluid is necessary; this will help in guiding the needle during aspiration. Jill also has experienced chills and a fever, so a CBC with differential and a culture for bacterial identification and sensitivities of antibiotics should be done at the time of the breast aspiration. Which differential diagnoses should be considered? Mastitis, cellulitis, nonpuerperal breast abscess, periductal mastitis inflammatory breast cancer Which is the most likely differential diagnosis and why? Nonpuerperal breast abscess: Jill is G0P0; she underwent nipple piercings 3 months ago while vacationing in the Caribbean. She noticed redness on the right breast 4 days ago accompanied by swelling, pain, erythema, drainage, and fever. Nipple piercing has become common and there is little regulation of the studios where piercing is done. Complications from the procedure may include breast infection, allergic reactions to the jewelry that is used, and scarring. The channels of the piercing may take a long time to heal, increasing the risk for infections. The onset of breast infection following nipple piercing can occur days to months after the event. Other risk factors for development of nonpuerperal breast abscesses in addition to nipple piercings are nicotine use: the breast concentrates cotinine, a derivative of nic-otine, in the subareolar ducts; this in turn damages the subareolar ducts, leading to tissue necrosis and subsequent infection, diabetes (DM), and periductal mastitis, a condition that causes inflamed ducts that can rupture and lead to abscess formation (Dixon, 2017). The culture from the ultrasound‐guided aspiration of Jill's abscess grew out Streptococcus Group B. The literature shows that the most common organisms associated with nipple piercing are Mycobacterium, Gram‐negative Staphylococcus, and Streptococcus Group B. In contrast to
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424 Resolutions patients who have breast abscesses not associated with nipple piercings, in this setting the bacteria more commonly found are Staphylococcus aureus (with an increasing association with methicillin‐resistant Staphylococcus aureus), Pseudomonas aeruginosa, and Proteus mirabilis (Dixon, 2017). What is the plan of treatment? Traditional first‐line treatment of both puerperal and nonpuerperal breast abscesses had previ-ously consisted of incision and drainage of the breast coupled with antibiotic therapy; however, several studies have reported clinical success treating breast abscesses with diagnostic ultrasound followed by needle aspiration and antibiotic therapy with close clinical follow‐up. Aspiration has supplanted surgical incision and drainage as first‐line management of both puerperal and nonpuerperal abscesses in many clinical situations (Geiss, Golshan, Flaherty & Birdwell, 2014). Fluid obtained from the aspiration is sent to the lab for microbiology to identify the causative organism and tested for bacterial sensitivities. The most commonly found organisms in soft tissue infections of the breast are Staphylococcus species and Streptococcus species. Effective antibiotics to be used to treat the infection (in the absence of risk factors for MRSA) would be Dicloxacillin 500 mg 4 times daily × 7-10 days, Cephalexin 500 mg 4 times daily × 7-10 days, or Clindamycin 300 to 400 mg 3 times daily × 7-10 days. In the setting of infection with risk factors for MRSA (recent hospitalization, residing in a long‐term‐care facility, recent surgery, hemodialysis, or HIV infection), Trimethoprim‐Sulfamethoxazole DS 1 tablet every 12 hours × 10 days or Clindamycin 300-450 mg 4 times daily × 7-10 days (Dixon, 2017). What is the plan for follow‐up? The patient should return in 2-3 days for a follow‐up ultrasound to check for reaccumulation of the fluid and may need a second aspiration. If a second aspiration is needed, see the patient again in 2-3 days for another follow‐up ultrasound. If there is no further need for ultrasound and aspira-tion, then the patient may follow up when the antibiotics are completed. Patients should have annual clinical breast exams by the primary care provider beginning at age 25 and have an annual mammogram alternating with breast MRI 10 years before the onset of breast cancer in any family members. Jill should have an MRI at age 33 due to a breast cancer diagnosis in her paternal grand-mother at age 43. This relative was a known BRCA 2 mutation carrier. Would the work‐up or treatment be different if this patient were a man? Men also can develop these abscesses from piercings or from gynecomastia that can cause blockage in the ducts. The evaluation and treatment plan would be the same. Are any referrals needed? A referral to a breast surgeon should be made if the patient fails to improve after aspiration and treatment with antibiotics or if the patient improves but symptoms recur after a few months. The ducts may stay obstructed and require surgical resection for successful resolution of the problem. What health education is important for this patient? Jill should be instructed in the following: Take antibiotics as directed; complete the entire course of medication. Report symptoms: Temp > 101, increase in drainage, redness, pain, or swelling. Manage pain with warm compresses to the area 2-3 times per day, take pain medication as directed, and wear a supportive bra. Cellulitis should improve within 48 hours after starting the antibiotics. If the clinician has outlined the area of redness on the breast, the patient should call if the redness progresses beyond the outline. The patent should not reinsert the nipple jewelry and should try to stop smoking.
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Redness and Swelling in the Breast 425 REFERENCES AND RESOURCES Crico. (2014). Breast care management algorithm: A decision support tool. www. rmf. harvard. edu/guidebreasts Fahmi, M., Schwarz, E. I., Stadimann, S., Singer, G., Hauser, N., & Kubik‐Huch, R. A. (2012). Breast abscesses: Diagnosis, treatment and outcome. Breast Care, 7(1), 32-38. Dixon, J. M. (2017). Nonlactational mastitis in adults. Up To Date. Retrieved from www. uptodate. com Giess, C. S., Golshan, M., Flaherty, K., & Birdwell, R. (2014). Clinical experience with aspiration of breast abscesses based on size and etiology at an academic medical center. Journal of Clinical Oncology, 42(9), 513-521. Leibman, A. J., Misra, M., & Castaldi, M. (2011). Breast abscess after nipple piercing. Journal of Ultrasound in Medicine, 30(9).
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427 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 6. 7 Sexual Assault RESOLUTION What is the most likely differential diagnosis in this case and why? Sexual assault: Although Aiyata does not disclose a sexual assault, one should be suspected in her case. Consuming alcohol to the point in which the individual becomes impaired and cannot consent to intercourse leads to a strong suspicion of assault. In addition, the male friend gave her the drinks and her behaviors after drinking these drinks impaired her memory. A drug‐facilitated sexual assault should be suspected. Which diagnostic tests are required in this case and why? CBC with differential: CBC testing may be useful in a patient who is bleeding to determine HGB and HCT and to determine whether the patient is anemic. Metabolic panel: Metabolic labs should be performed to obtain baseline levels if the patient is going to beginning HIV post‐exposure prophylaxis (PEP). While taking HIV PEP, some patients can develop abnormal kidney function as evidenced by the BUN and creatinine, so baseline data will help to monitor patients. LFTs: LFTs to obtain baseline levels should be performed if the patient is going to begin HIV PEP. Some patients can develop abnormal LFTs while taking HIV PEP. Toxicology: Routine toxicology is not recommended for sexual assault patients unless a drug‐ facilitated assault is suspected. In this patient, given the memory loss and history of drinks, a drug‐facilitated assault is suspected, so toxicology testing should be performed. Many hospital laboratories are not equipped to perform the specific testing to detect the presence of date rape drugs. You may need to refer to specialized laboratories for toxicology testing in cases of suspected drug‐facilitated sexual assault. HCG: HCG is an essential test that should be performed to establish whether the patient is preg-nant. A positive pregnancy test result will require changes to the treatment plan and medications. HIV: HIV testing should be performed on patients who have been sexually assaulted, especially in cases where the assault is at high risk for HIV and the patient is going to begin HIV PEP. HIV testing will provide the baseline HIV status. HIV testing is a sensitive topic for many patients so the patient should have access to proper counseling in cases of positive results.
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428 Resolutions Urinalysis: Routine urinalysis may be considered; however, since the dysuria this patient reported was most likely due to trauma and not to a UTI, a urinalysis in this case would not be diagnostic. Urine NAAT: Urine NAAT is recommended for testing for gonorrhea, chlamydia, and trichomonas. CT scan of neck: A CT of the neck should be a priority diagnostic test for this patient. The patient has positive signs and symptoms of possible strangulation. Her lateral neck is tender to palpation, there are dark red ecchymosed areas on the right side of the neck, and subconjunctival hemor-rhages. All of these can be physical signs of strangulation. In addition, this patient has poor memory recall, which may also result from strangulation and hypoperfusion. A CT scan of the neck is war-ranted to determine any soft tissue injury to the trachea or neck ligatures. What are the concerns at this point? The initial concern is that this patient has been sexually assaulted and that a drug‐facilitated assault is suspected with injuries. What is the plan of treatment? Caring for patients who have been sexually assaulted requires three aspects of care: (1) medical eval-uation, (2) psychological evaluation, and (3) forensic evaluation. The medical evaluation process includes general medical care and treatment for the prevention of sexually transmitted infections and pregnancy. Assessments should first always address life‐threatening, serious, or time‐sensitive needs. All patients should be assessed for injuries. Injuries can present at different time periods after an assault. Although strangulation was not disclosed, the patient presented with several red flags indicating possible strangulation, which can be a life‐threatening injury. If strangulation is sus-pected, the patient should be specifically asked about strangulation to determine if she has any memories that may help guide the assessment and treatment plan. This patient should have a CT scan of the neck to determine if there are any soft tissue injuries to the neck. Unless this patient declines, she should receive post‐exposure prophylaxis treatment for sexually transmitted infec-tions, HIV, and pregnancy. What are the plans for referral and follow‐up care? All patients who disclose or for whom sexual assault is suspected should be referred for or offered a medical forensic examination with evidence collection. Patients should be referred to any health care facility that has sexual assault response teams (SARTs) or sexual assault nurse examiners (SANEs). SARTs and SANEs provide expert‐level care, including medical forensic examination. The purpose of a medical forensic exam with evidence collection is to provide law enforcement with details and evidence from the assault. A medical forensic examination with evidence collec-tion is a lengthy process that includes consent, medical forensic interview, documentation, and a lengthy evidence collection process. If patients decline the medical forensic examination, they should be informed of the risks and benefits of a prompt evaluation and their right to obtain one in the future according to local jurisdictional practices. Sexual assault can have significant psychological impact on patients. All patients should be referred to local rape crisis counselors. Many local rape crisis centers have advocates and resources that support sexually assaulted patients throughout the recovery process. They help address immediate and long‐term safety issues and the mental and emotional health needs of the patient. Many patients who have been sexually assaulted will begin several types of prophylactic medi-cations. Patients will need follow‐up testing for HIV and STIs and blood monitoring if the patient is taking HIV PEP. All patients should be assessed for safety. In many cases of sexual assault, the assailant is known to the individual and there is genuine concern for safety. Make referrals to law enforcement or social work to help navigate concerns for safety or in cases where there is a need for restraining orders.
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Sexual Assault 429 Mandatory reporting of patients who have been sexually assaulted differs from state to state. It is important to know your local mandatory reporting requirements and the agencies to which you report. What health education should be provided to this patient? Education for this patient should include the importance of follow‐up care and completing the course of HIV PEP medications. Many patients will receive the one‐time post‐exposure medica-tions in the health care setting. HIV PEP requires completion of a 28‐day course to be effective. Adherence to the 28‐day course is often poor for sexually assaulted patients. Patients need be edu-cated on the importance of completing HIV PEP medications and follow up with health care pro-viders for additional bloodwork and testing. Are there any standardized guidelines that should be used to assess or treat this case? The United States Department of Justice Office on Violence Against Women has made publicly available the National Protocol for Sexual Assault Medical Forensic Examinations (https://www. ncjrs. gov/pdffiles1/ovw/241903. pdf). This guideline details a comprehensive approach in consid-ering the medical, psychosocial, and forensic considerations when caring for patients who have been sexually assaulted. REFERENCES AND RESOURCES Centers for Disease Control and Prevention, U. S. Department of Health and Human Services. (2016). Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupa-tional exposure to HI-United States. 2016 n PEP Guidelines Update, 1-91. Retrieved from https://www. cdc. gov/hiv/pdf/programresources/cdc‐hiv‐npep‐guidelines. pdf Scannell, M., Kim, T., & Guthrie, B. J. (2018). A meta‐analysis of HIV post exposure prophylaxis among sexu-ally assaulted patients in the United States. Journal of the Association of Nurses in AIDS Care, 29(1), 60-69. U. S. Department of Justice (DOJ), Office on Violence Against Women. (2013). A national protocol for sexual assault medical forensic examinations: Adults/adolescents (2nd ed. ). Retrieved from https://www. ncjrs. gov/pdffiles1/ovw/241903. pdf
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431 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 6. 8 Abdominal Pain RESOLUTION What is the most likely differential diagnosis and why? Rachel has cholecystitis. The positive Murphy's sign with RUQ pain and nausea support the diag-nosis. Her fatty diet clearly contributes to her condition, even though she denies any associated pattern with food. The abdominal ultrasound, usually diagnostic, was inconclusive in this case but the HIDA scan confirmed the diagnosis of cholecystitis. Which diagnostic tests are required in this case and why? In addition to urine testing, Rachel should have had a comprehensive metabolic panel, hepatic function panel, lipase and amylase, and CBC. The CBC shows a left shift. Once her fasting blood sugar was noted to be 45 mg/d L, a fasting insulin level, c‐peptide, and oral glucose tolerance test (OGTT) should have been ordered. Her first insulin level was 43 u IU/m L (normal ≤ 17), and her c‐peptide was 5. 1 (normal = 0. 8-3. 1 ng/m L). These levels are suspicious for an insulinoma. A gastric tumor must also be ruled out as Rachel has abdominal pain. Therefore, a gastrin level was obtained, which was normal. Rachel told the clinician that she had not eaten when the test was done. It was necessary to repeat this to be sure that Rachel fasted, and the best way to do this was to have these labs repeated just prior to beginning the OGTT, which would also support or refute a diagnosis of an insulinoma. Rachel's fasting levels, including the OGTT, turned out to be normal, and both an insulin tumor and a gastric tumor were ruled out. The abdominal pain required an abdominal ultrasound to confirm or rule out cholecystitis or gallstones. If the results of the ultrasound are unclear, a cholescintigraphy (hepatic iminodiacetic acid [HIDA] scan can confirm the diagnosis. When Rachel mentioned the new‐onset headache, the nurse practitioner performed a focused neurological assessment and suggested that Rachel make an appointment with an ophthalmologist for visual screening and instructed her in the appropriate use of analgesics. She was told to call 911 or go to the emergency room if her vision or headaches got worse. Imaging is not indicated at this time. Rachel returns in 2 weeks and states she is following a low‐fat diet per your recommendations and her abdominal pain feels slightly better. Now, she denies any headaches, nausea, and dizziness. On exam, she has RUQ TTP and a positive Murphy's sign.
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432 Resolutions What is the plan of treatment? Rachel should be referred to a medical social worker who can advise her about transportation to future medical appointments and elsewhere in her community. Rachel should be asked to return to the clinic to review her diet progress. It is advisable to rec-ommend that Rachel stop smoking for the sake of herself and her baby. Are any referrals needed? A referral may be needed to a gastroenterologist to further assess the cholecystitis and to establish a baseline for the condition of the gallbladder as surgical options are considered. Does the patient's home situation influence the plan? Rachel's home life does play a role in her care. She has trouble getting her in‐laws to support her need for transportation or her boyfriend to support her need for socialization. The clinician should coach her and provide support to assist her in helping her in‐laws and boyfriend to understand that she needs transportation for her health needs and those of her baby and also to help her make friends in her new location. Rachel is at risk for depression and the consequences of social isolation. This could then put her at high risk for child abuse. The clinician should also offer to speak with the family. It is important that the clinician act as a confidante and support for Rachel while being careful not to malign her family. Are there any standardized guidelines that should be used to treat this case? The American College of Gastroenterology is a good resource. Upto Date is also a useful resource for current information. REFERENCES AND RESOURCES Siddiqui, A. A. (2018). Gallbladder and bile duct disorders. In R. S. Porter, J. L. Kaplan, R. B. Lynn, & M. T. Reddy (Eds. ), The Merck manual of diagnosis and therapy (pp. 215-216). Kenilworth, NJ: Merck Sharp & Dohme Corp.
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433 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 6. 9 Urinary Frequency RESOLUTION What is the most likely differential diagnosis and why? Acute cystitis or a UTI: A UTI is characterized by difficulty with voiding and a positive urine culture. The patient is usually afebrile. Urgency, frequency, and pain with voiding are common, as is some pain following sexual activity. Some women experience hematuria, as well. A new partner for Susan is a risk factor for a UTI. Interstitial cystitis is a diagnosis of exclusion and a negative urine culture is an essential part of the diagnosis. Other causes of urinary urgency must first be ruled out. Pyelonephritis is character-ized by flank pain in addition to dysuria, urgency, frequency, and a positive urine culture. Fever and chills are typically present. If the clinician is in doubt about Susan having pyelonephritis, a CBC could be added to the workup, as it will show definite leukocytosis. For this case, none of the other diagnostic tests that are listed are necessary at this time. However, if Susan's symptoms get worse, a renal scan to look for hydronephrosis might be warranted. Which diagnostic studies should be considered to assist with or confirm the diagnosis? The clinician checks a urine dipstick while Susan is in the office. The results are negative except for positive leukocytes and positive nitrites. A rapid HCG is performed. If Susan is not pregnant, the clinician can simply treat her without sending out for a complete urinalysis and culture and sensi-tivity. The pelvic exam was helpful in Susan's case to rule out PID or vulvovaginitis. Susan has a family history of diabetes mellitus, so a fasting blood sugar should also be included in her workup. People with DM are often prone to UTIs. What is the plan of treatment? In Susan's case, the UTI is uncomplicated and could therefore be treated with a short course of anti-biotics. Nitrofurantoin (check a creatinine clearance before using) or Bactrim are good choices. It is important to check your region for antibiotic resistance. Phenazopyridine obtained over the counter can help relieve pain with urination, but the patient should be warned that the medication will stain clothes orange. Susan should be encouraged to push fluids until she feels better and in the future to help prevent UTIs. If Susan's tests were negative for a UTI and there is no other apparent reason for her suprapubic pain, then she should have a workup for abdominal pain.
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434 Resolutions What is the plan for referrals and follow‐up? No referrals are need at this time, but a referral to a urologist might be in order if the patient has recurrent episodes or is found to have a stone. Would the diagnosis change if the patient had fever and flank pain? Pyelonephritis should be suspected if the patent develops fever or flank pain. Asymptomatic bacteriuria should not be treated unless the patient is pr egnant, an older adult, has diabetes mellitus, has an indwelling catheter, or is at risk for complications. Would the most likely diagnosis change if the patient were male? If the patient were male, the likelihood of a UTI is less and is of more concern when it happens. It is important to determine the etiology of the symptoms in a male to help determine a plan of treatment. Prostatitis, epididymitis, and sexually transmitted infection are possible causes of urinary symptoms in men. A urinalysis and culture should be ordered. What is an important symptom to consider in an older adult? An older adult may not have any symptoms other than delirium. New onset of confusion should trigger lab testing for a UTI. What if Susan were pregnant? At approximately 12 weeks' gestation, the pregnant woman should be evaluated for a UTI to prevent low‐birth‐weight infants and poor delivery outcomes. A urinalysis and urine culture should be ordered. Avoid Bactrim and sulfa drugs if the patient is pregnant. REFERENCES AND RESOURCES Imam, T. I. (2018). Bacterial urinary infections. In R. S. Porter, J. L. Kaplan, R. B. Lynn, & M. T. Reddy (Eds. ), The Merck manual of diagnosis and therapy (pp. 2176-2180). Kenilworth, NJ: Merck Sharp & Dohme Corp. Gupta, K., Hooton, T. M., Naber, K. G., Wullt, B., Colgan, R., Miller, L. G., . . . Soper, D. E. (2011). International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases, 52, e103-e120. doi:10. 1093/cid/ciq257
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435 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 6. 10 Headaches RESOLUTION What is the most likely differential diagnosis and why? Migraine with aura: Because these are new‐onset headaches and also because Sophia's family history is significant for an uncle with a brain tumor, it is important to rule out other causes of her headaches, such as a brain tumor or aneurysm. Sophia's headaches appear to have an aura, because she has noticed “spots” in front of her eyes just before onset. Cluster headaches are more common in men, tend to occur over one side of the head or one eye, are excruciating and often explosive, and may also involve ipsilateral eye tearing. Patients tend to describe tension headaches as being bandlike and will motion to the temporal areas of the head bilaterally when describing the location of the pain. The headaches usually go away with rest or diversionary activities. Meningeal irritation tends to cause neck stiffness and fever as well as headache, and Brudzinski and Kernig signs tend to be positive. Sophia is too young to have temporal arteritis, a condition that is typically associated with polymyalgia rheumatica (PMR), a disease of adults over age 50 that presents with shoulder and hip girdle pain. Patients with temporal arteritis tend to have headache, possible jaw claudication, scalp or facial tenderness, and possibly diplopia. Patients who are suspected of having PMR or temporal arteritis should have an ESR done. Typically, the ESR will be very high (over 50) in these cases. High doses of prednisone are typically given to treat both conditions, and a rheumatologist should be consulted as part of the treatment plan. Sophia might have a psychogenic headache but her history does not support this condition. That type of headache is more often bilateral and does not follow any particular pattern. Sophia's head-aches are throbbing, unilateral, accompanied by nausea, preceded by an aura, and disappear with sleep. These migraines typically occur in women aged 30 to 50 years, and they often run in families. There are various migraine triggers, such as hormonal changes (many women have premenstrual migraines), missed meals, certain foods such as chocolate or red wine, weather changes, stress or tension, birth control pills, nitrates, monosodium glutamate, tyramine, caffeine, vasodilation from any source, lack of sleep, glaring or flickering lights, aspartame, smoking, and alcohol use.
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436 Resolutions Are there tools that can be used to help assess this headache? If so, name two. 1. ID Migraine (Rapoport & Bigal, 2004): During the past 3 months, did you have the following with your headaches? You felt nauseated or sick to your stomach. Light bothered you (a lot mor e than when you do not have headaches). Your headaches limited your ability to work, study, or do what you needed to do for at least 1 day. The ID Migraine screen is positive if 2 of the 3 items are answered in the affirmative. 2. The brief headache screen (Maizels & Bur chette, 2003): How often do you get severe headaches (i. e., without tr eatment, it is difficult to function)? How often do you get other (milder) headaches? How often do you take headache relievers or pain pills? Has there been any r ecent change in your headaches? Which diagnostic studies should be considered? An MRI scan is appropriate, and a CBC with differential would be helpful to rule out infection and anemia as causes of the headaches. Whether to use contrast media with the MRI depends on the specific indications. If imaging the blood vessels, a CTA or MRA should supplement the MRI or CT scan and requires IV contrast. For a sudden, severe headache, get a CT scan of the head without contrast or possibly a CT with contrast. If the patient has a new‐onset headache with optic disc edema, initially an MRI of the head with and without contrast are appropriate, as is a CT scan without contrast. Red flags, such as head trauma, a headache that worsens with activity, cancer, immunosuppression, an immunocompromised status, pregnancy, or age over 50 years, require other or additional imaging. SNOOP (up to date) can be used to remember red flags: Systemic symptoms Neurologic symptoms Onset (new, especially if new over age 50 years, or sudden) Other associated conditions Previous headache history with pr ogression or change What is the plan of treatment? Migraine treatment can target suppressive therapy if the patient has several migraines in 1 week, abortive therapy (at the time of onset) or post migraine. Examples of suppressive therapy include NSAIDs, acetaminophen, SSRIs, valproate or topiramate, propranolol or metoprolol or timolol, and amitriptyline and venlafaxine. Abortive therapies include metoclopramide (an antiemetic), triptans, and ergotamines. If the patient is vomiting, add an antiemetic medicine. CGRP antago-nists such as erenumab are not used first line but might be used in patients who are disabled by their migraine headaches or cannot tolerate other medicines. Sophia is of child‐bearing age, so we might consider verapamil or flunarizine. Do not give her valproate or topiramate if she is or might become pregnant. It is important to carefully consider the medication options along with Sophia's individual needs and characteristics. Starting with a low dose and titrating upward is best practice. Do not give opioids or barbiturates to treat migraine. If appropriate, consider a CT or MRI scan first to rule out other causes. Advising the patient to keep a headache diary in order to avoid triggers, as well as to retreat to a dark quiet room at the onset of the migraine, would also be helpful. Sophia should be seen for follow‐up after 1 week to titrate the medicine as necessary and to review test and lab results. Are any referrals or follow‐up needed? If the CT or MRI scan is abnormal or Sophia exhibits neurological deficits, she should be sent to the emergency department to see a neurologist. If Sophia were older and temporal arteritis was sus-pected, she would be referred immediately for an ophthalmologic consult to prevent vision loss.
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Headaches 437 Does the patient's psychosocial history impact how she might be treated? Sophia's level of stress probably does impact her migraines; counseling regarding stress reduction and relaxation exercises may be helpful. Is the patient's blood pressure the cause or the result of her headache? Sophia's blood pressure may be a result of her headache pain. However, follow‐up when she is not in pain is warranted to evaluate her for hypertension. Would the treatment change if the patient were a smoker or on birth control pills? If Sophia were a smoker or on birth control pills, she would be encouraged to stop smoking (for overall health and because smoking is a migraine trigger). Birth control pills can be a trigger for migraine, and patients with a migraine with aura should discontinue or not start birth control pills. Furthermore, smoking and the use of birth control pills can significantly increase the risk of deep vein thrombosis. REFERENCE AND RESOURCE Maizels, M., & Burchette, R. (2003). Rapid and sensitive paradigm for screening patients with headaches in primary care settings. Headache, 43(5), 441. Rapoport, A. M., & Bigal, M. E. (2004). ID‐migraine. Neurological Science, 25(Suppl 3), S258.
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439 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 6. 11 Fatigue and Joint Pain RESOLUTION What is the most likely differential diagnosis and why? Systemic lupus erythematosus (SLE): SLE is most commonly seen in African American women with an onset typically between the ages of 20 and 30 years. However, Caucasian women and men also get SLE, and anyone can get it at a younger age. Only 10% of people with SLE have a family member with the disease. The development of autoantibodies and the presence of low complements are typical of SLE and are chiefly respon-sible for its symptoms. There is potential for multiorgan involvement (Petri, 2007). The following environmental factors have been correlated with SLE, both onset and flares: ultra-violet light (UVA and UVB), echinacea, smoking, Epstein‐Barr virus, silica exposure, and mercury exposure. Risk of developing SLE can be increased by the use of oral contraceptives or hormone replacement therapy. However, only HRT has been found to contribute to flares. Although the dis-ease typically includes relapses and remissions, it can be characterized by continuous symptoms (Petri, 2007). The American College of Rheumatology (ACR) is the most commonly used source for diagnosis of SLE. The patient must meet 4 of the following 11 criteria to be diagnosed with SLE: Malar rash Discoid rash Photosensitivity Oral ulcers Arthritis Serositis Renal disorder Hematologic disorder Neurologic disor der Immunologic disorder Positive ANA Differ ential diagnoses (or co‐diagnoses with SLE) include Sjögren's syndrome (dry eyes, dry mouth), fibromyalgia (muscle tender points), multiple areas of inflammation of cartilage (polychondritis),
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440 Resolutions and involvement of the eyes (such as scleritis). Elevated liver enzymes are not unusual. Patients with SLE may have cognitive changes, seizures, and stroke; and many have antiphospholipid syn-drome (APL). APL can affect a woman's ability to deliver healthy normal children. Nephritis is another possible sequela but is often asymptomatic. Aliyah has a malar rash (spares the nasolabial folds), livedo reticularis, nail fold capillary loops (all are very indicative of SLE), alopecia, nasal and oral ulcers, fever, weight loss, fatigue, lymph-adenopathy, and polyarthritis. Which diagnostic studies should be considered to assist with or confirm the diagnosis? A CBC with differential will help determine if the patient has anemia or chronic disease, leuko-penia, lymphopenia, or thrombocytopenia, which are all possible with systemic lupus erythema-tosus (SLE). An increased ESR and/or CRP will indicate active inflammation, but neither informs the clinician regarding disease or flare severity. Lipids may be abnormal due to renal dysfunction or prednisone use. In addition, the CK level may indicate myositis and the homocysteine level can be indicative of atherosclerosis or renal dysfunction. The ANA is positive in most patients with SLE. However, healthy persons can have a positive ANA. The ANA titer is most helpful because it indicates the presence of connective tissue disease. A titer of 1:640 or higher is indicative. If the ANA is positive, then perform the ds DNA, anti‐Sm, Ro/SSA, La/SSB and U1 ribonucleoprotein (RNP) tests. Some labs reflex automatically from a positive ANA to these tests. The anti‐DS DNA and anti‐SM (Smith) tests are highly specific but not necessarily highly sensitive for SLE. Antiphospholipid (APL) antibodies (lupus anticoagulant, anti‐Beta 2 glycoprotein‐1) are present in half of patients with SLE at some point in the course of the disease. These antibodies are associated with an increased risk of blood clots and pregnancy losses. Anti‐Ro/SSA and anti‐La/SSB may be present in a patient with SLE but are more specific for Sjogren's syndrome. Anti‐U1 RNP occurs in about a quarter of patients with SLE but is often present if the patient has a mixed connective dis-ease condition. Decreased C3 and C4, while unspecific, are often present and can help signal a flare. X‐rays of the hands and wrists will not show erosion as in rheumatoid arthritis. Ultrasound can detect synovitis or swelling that is not visible on examination. Other imaging should be chosen based on patient systems and the body system that is under suspicion for involvement, such as renal, pulmonary, cardiac, abdomen, or brain. Aliyah complained of a cough so a chest X‐ray might be appropriate at this time. An elevated serum creatinine, BUN, and/or proteinuria can be indicative of renal dysfunction. A renal biopsy is required to investigate this further. The urine should be examined for hematuria and red blood cell casts (Petri, 2007). If the ANA is negative but the clinician suspects SLE, then perform a rheumatoid factor test and check for anti‐CCP antibodies. This will help exclude or include rheumatoid arthritis as the diag-nosis. If the history indicates a possibility of infection, check for infections such as parvovirus, hepatitis B and C, tick‐borne illnesses, or other infections. What is the plan of treatment? Aliyah should be instructed to get exercise, rest, eat nutritiously, protect the skin from the sun, and stop smoking. Patients with SLE frequently have low vitamin D levels so levels should be moni-tored and treated as appropriate. If she had hypertension or abnormal lipids, those should be well managed to avoid atherosclerosis and renal dysfunction. Aliyah should receive influenza and pneumonia vaccines to protect her from opportunistic infections. Her bone density should be mon-itored, especially if steroids are used to help control flares. Topical glucocorticoids are typically used to help cutaneous lupus. However, a referral to a dermatologist is sensible if the patient has cutaneous symptoms. SLE is initially treated with NSAIDs. These should be accompanied by a proton pump inhibitor to protect the gastrointestinal tract. However, a patient with Aliyah's symptoms would probably be
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Fatigue and Joint Pain 441 started on Plaquenil (hydroxychloroquine), as it slows progression of the disease and helps symptoms. It is usually given at doses of 200-400 mg daily. It can cause retinal damage, so it is important for the patient to have a baseline and annual eye examination by an ophthalmologist. Prednisone is often used to control flares and methotrexate is used to supplement Plaquenil. Biologic immunosuppressive treatments, such as rituximab or cyclosporine, or azathioprine may be ordered by the rheumatologist. What is the plan for referrals and follow‐up? Patients who are diagnosed with SLE or discoid lupus should be referred to a rheumatologist. However, it is not always possible to get patients in to see the rheumatologist right away. In the meantime, the rheumatologist can be consulted by telephone and the patient can be started on NSAIDs or Plaquenil. The patient should follow up with primary care for her general health care needs; however, follow‐up pertaining to the SLE will most likely occur with the rheumatologist. Are there other manifestations of this disease? If discoid lupus skin lesions are suspected, it is important to order a skin biopsy. Nerve conduction studies and biopsies can help identify vasculitis and myositis. Would it change the diagnosis or impact the prognosis or treatment if the patient were taking minocycline? What if the patient had a parvovirus? Minocycline along with tumor necrosis factor alpha inhibitors can cause drug‐induced lupus. Symptoms should resolve after removing the causal agent. Parvovirus, HIV, hepatitis, and malig-nancy can also cause lupus‐like symptoms (Petri, 2007). What are the potential complications of this disease? Organ damage may occur as a result of the disease itself, prolonged steroid treatment, interstitial pulmonary fibrosis, renal complications, and atherosclerosis. Other complications include pleuritic pain, pleural effusions, pericarditis, pulmonary hypertension, and esophageal abnormalities (Petri, 2007). REFERENCES AND RESOURCES Belmont, H. M. (2013). Treatment of systemic lupus erythematosus—2013 update. Bulletin for the Hospital of Joint Diseases, 71, 208. Bertsias, G., Ioannidis, J. P., Boletis, J., Bombardieri, S., Cervera, R., Dostal, C., Font, J., . . . Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics. (2008). EULAR rec-ommendations for the management of systemic lupus erythematosus. Report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics. Annals of Rheumatic Diseases, 67,195. Gladman, D. D., Pisetsky, D. S., & Curtis, M. R. (2018). Systemic lupus erythematosus. Up To Date. Gordon, C., Amissah‐Arthur, M. B., Gayed, M., Brown, S., Bruce, I. N., D'Cruz, D., . . . Isenberg, D., for the British Society for Rheumatology Standards, Audit and Guidelines Working Group. (2018). The British Society for Rheumatology guideline for the management of systemic lupus erythematosus in adults. Rheumatology (Oxford), 57,e1-e45. Hochberg, M. C. (1997). Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus (letter). Arthritis & Rheumatology, 40, 1725. Petri, M. (2007). Monitoring systemic lupus erythematosus in standard clinical care. Best Practice & Research in Clinical Rheumatology, 21(4), 687-697. Petri, M., Orbai, A. M., Alarcón, G. S., Gordon, C., Merrill, J. T., Fortin, P. R., . . . Magder, L. S. (2012). Derivation and validation of the Systemic Lupus International Collaborating Clinics classification criteria for systemic lupus erythematosus. Arthritis & Rheumatology, 64, 2677-2686.
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442 Resolutions Pons‐Estel, B. A., Bonfa, E., Soriano, E. R., Cardiel, M. H., Izcovich, A., Popoff, F., . . . Alarcón, G. S., on behalf of the Grupo Americano de Estudio del Lupus (GLADEL) and Pan‐American League of Associations of Rheumatology (PANLAR). (2018). First Latin American clinical practice guidelines for the treatment of systemic lupus erythematosus: Latin American Group for the Study of Lupus (GLADEL, Grupo Latino Americano de Estudio del Lupus)‐Pan‐American League of Associations of Rheumatology (PANLAR). Annals of Rheumatic Diseases 77, 1549-1557. Tan, E. M., Cohen, A. S., Fries, J. F., Masi, A. T., Mc Shane, D. J., . . . Winchester, R. J.. (1982). The 1982 revised criteria for the classification of systemic lupus erythematosus. Arthritis & Rheumatology, 25, 1271-1277. Toloza, S. M., Cole, D. E., Gladman, D. D., Ibañez, D., & Urowitz, M. B.. (2010). Vitamin D insufficiency in a large female SLE cohort. Lupus 19, 13-19. van Vollenhoven, R. F., Mosca, M., Bertsias, G., Isenberg, D., Kuhn, A., Lerstrøm, K., . . . Schneier, M.. (2014). Treat‐to‐target in systemic lupus erythematosus: Recommendations from an international task force. Annals of Rheumatic Diseases, 73, 958-967. Wallace, D. J. (2008). Improving the prognosis of SLE without prescribing lupus drugs and the primary care paradox. Lupus, 17, 91. Wallace, D. J., Pisetsky, D. S., Schur, P. H., & Curtis, M. R. (2019). Systemic lupus Eeythematosus treatment. Up To Date.
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443 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 6. 12 Muscle Tender ness RESOLUTION What is the most likely differential diagnosis and why? Fibromyalgia (FM): The following data support this diagnosis: Widespread pain for longer than 3 months, occurring bilaterally and above and below the waist. Patients with FM also typically have sleep disorders, depression and/or anxiety, stressful or dysfunctional childhoods and current lifestyles, and fatigue. People with FM often have burning pain and perceive that they have joint swelling but do not have it on examination. The inability to concentrate is not uncommon, and these patients often have a coexisting problem such as irritable bowel syndrome, chronic fatigue, or another systemic disease. Which diagnostic studies should be considered to assist with or confirm the diagnosis? Zelda has widespread pain for more than 3 months. If the history or exam raised suspicion for other illnesses, then labwork, such as ESR, rheumatoid factor, and anti‐CCP and an ANA should be pursued to rule out these illnesses. However, other than a suspicion of pregnancy, Zelda does not have any symptoms that would suggest any of these other diseases. She should have an HCG to rule out pregnancy. Therefore, she should not undergo unnecessary testing. If she has not been tested recently for thyroid disease, a TSH should be considered, although fatigue seems to be her only relevant symptom. What is the plan of treatment? Zelda should be encouraged to lose weight, to eat more fruits and vegetables, to exercise, and to reduce her stress level. Aquatic therapy can be useful. She will probably benefit from counseling to help her through this period of stress. However, her insurance may not cover it. Cognitive behavioral therapy (CBT) often helps, as can hypnotherapy. Encouraging her to engage in pleasur-able activities, both alone and with her children, will help distract her from her difficulties and from her symptoms. Zelda should be taught sleep hygiene activities so she can improve her sleep without sleeping aids, if possible. If a sleeping aid is necessary, use a nonbenzodiazepine and con-sider a sleep study to fully evaluate the quality of sleep.
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Leslie Neal-Boylan - The Family Nurse Practitioner.pdf
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444 Resolutions Antidepressants can help both the symptoms of FM and the depression Zelda has been experi-encing. Cymbalta (Duloxetine), 30-60 mg, is a good option as it helps both physical pain and depression. However, a less expensive alternative that works quite well is the use of amitriptyline (10-15 mg) at bedtime to help with anxiety and sleep alone or in combination with an SSRI taken in the morning. Effexor (venlafaxine), like Cymbalta, 150-225 mg daily, combines norepinephrine and epinephrine, which help decrease all of the symptoms of FM. Anxiolytics may be pursued as adjunct therapy if the patient is anxious, but should be pursued carefully and only for as long as needed. For a patient who has hyperalgesia or allodynia to a severe degree, Neurontin (gabapentin) or Topamax (topiramate) titrated up at weekly intervals can help. Lyrica or pregabalin started at 75 mg daily and increased, if needed, to 150 mg twice each day, will make the patient sleepy and also help relieve symptoms. Savella (Milnacipran) is an alternative to Lyrica. The patient must get used to the drug, as daytime sleepiness can be initially a significant problem. Topical capsaicin can help relieve burning pain. Patients with FM should not be given opioid medications or NSAIDs to treat the condition, as these have been shown to not help and may worsen symptoms in the long run. Monosodium glu-tamate and aspartame can also worsen symptoms. What is the plan for referrals and follow‐up? A referral to a rheumatologist may be considered if the case is not straightforward or if there are confounding factors or symptoms that warrant suspicion of a connective tissue or inflammatory disorder. A referral to an orthopedist may be warranted if the patient is found to have joint pain or swelling with LROM on examination. Follow‐up care should be provided as necessary to monitor the effects of new medications and other treatment. The patient needs opportunities to be heard and reassured that the provider listens, understands, empathizes with her, and takes her concerns seriously. REFERENCE AND RESOURCE American College of Rheumatology, www. rheumatology. org Biundo, J. J. (2018). Fibromylagia. In R. S. Porter, J. L. Kaplan, R. B. Lynn, & M. T. Reddy (Eds. ), The Merck manual of diagnosis and therapy (p. 269). Kenilworth, NJ: Merck Sharp & Dohme Corp.
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Leslie Neal-Boylan - The Family Nurse Practitioner.pdf
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