Final Period- NCM 105 Maladaptive Patterns of Behavior Assignment No.

1: Concept on Anorexia Nervosa A 17 year old girl is brought to see a psychiatrist because her parents have become increasingly alarmed about her weight loss. The patient claims that her parents are worrying about nothing, and that she has come to the office just to appease them. She states that she feels fine, although her mood is slightly depressed. She denies having problems with sleeping or appetite and with any kind of drug or alcohol abuse. She says that she thinks she looks fat but that if she could lose another couple of ponds, she would be just right. She notes that her only problem is that she stopped having her period 3 months ago; she is not sexually active and therefore cannot be pregnant. When questioned separately, the parents report that the patient has been steadily losing weight over the past 8 months. The say that she started dieting after one of her friends commented that she looked a little lump. At that point, they noted that their daughter weighed approximately 120 lb. The patient lost 5 lb and according to the parents, felt good about the comments made by her friends. Since that time, she has eaten less and less. She now dresses in baggy clothes and does not discuss with her parents how much se weighs. Despite this, she helps her mother cook elaborate meals for party guests when the family entertains. She exercises throughout the day, and her parents say they can often hear her doing jumping jacks and sit ups in her room in the evening. On a physical examination, the patient is found to be 5ft in tall; she weighs 70lb and appears cachetic. Questions: 1. Considering the manifestation, is there any emergent problem seen? If so, what is the danger and what should be done to prevent complications? 2. What is the most likely diagnosis to the case given above? 3. What are the possible nursing diagnoses manifested to the case given above? 4. What is the best treatment for the patient? 5. Create a Care Map Summary: A 17 year old girl appears in a psychiatrists office grossly underweight. Despite this, she denies having any problems other than being mildly depressed, and she has not come to the office willingly. She views herself as overweight despite obvious appearances to the contrary. Her parents note that she has increasing restricted her intake of calories and exercises

excessively. She has been amenorrheic for the past several months. Most likely diagnosis: Anorexia Nervosa Next steps: The patient would benefit from hospitalization, but it is unlikely that she will agree, however, because she is 17 years old, her parents can sign her into a hospital without her consent. Her initial treatment should be aimed at restoring her nutritional status, as she is grossly malnourished. Dehydration, starvation and electrolyte imbalances must be corrected. The patient should be weighed daily and her daily fluid intake and output should be monitored. Therapy (behavioral management, individual psychotherapy, family education, and therapy) should also be started, but her unstable nutritional status needs to be addressed first. Assignment No. 2: Concept on Bipolar Disorder (Manic) A 27 year old man is brought to the emergency department by his friends and his roommate. The friends state that the patient had not slept for the past 3 or 4 weeks. They have noticed that he stays up all night cleaning his apartment. He has brought new computer equipment and a digital video disc player, although his roommate claims that the patient cannot afford these kinds of items. The patient has also been bragging to his friends that he has slept with three different women in the past week, behavior very unlike his usual self, and he has been very irritable and explosive. He has been drinking a lot of alcohol for the past 2 weeks, which uncharacteristic. The friends state that they have not seen the patient using drugs, and they do not think he has any medical problems or takes any prescription medication. They are not aware of any family history of medical or psychiatric disorders. They state that the patient is a graduate student in social work. On a mental status examination, the patient is noted to be alternately irritable and elated. He is wearing a bright orange top and red slacks, and his socks are mismatched. He paces the room and refuses to sit down when asked to do so by the examiner. His speech is rapid and loud, and it is hard to interrupts him. He claims that his mood is great, and he is very angry with his friends for insisting that he come to the emergency department. He states that they have probably insisted that he come because they are jealous of my success with women. He states that he is destined for greatness. His thought process are tangential. He denies having any suicidal or homicidal ideation, hallucinations, or delusions. Questions:

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2. 3. 4. 5.

Considering the manifestation, is there any emergent problem seen? If so, what is the danger and what should be done to prevent complications? What is the most likely diagnosis to the case given above? What are the possible nursing diagnoses manifested to the case given above? What is the best treatment for the patient? Create a Care Map

normal rate, rhythm and tone. His thought processes are tangential, and loose associations are occasionally noted. His thought content is positive for delusions and auditory hallucinations. He denies any suicidal or homicidal ideation. Questions: 1. Considering the manifestation, is there any emergent problem seen? If so, what is the danger and what should be done to prevent complications? 2. What is the most likely diagnosis to the case given above? 3. What are the possible nursing diagnoses manifested to the case given above? 4. What is the best treatment for the patient? 5. Create a Care Map Summary: A 21 year old man is brought to the emergency department after exhibiting bizarre and dangerous behavior. For at least 1 year, he experienced delusions, and auditory hallucinations. The hallucinations consist of several voices commenting on the patients behavior and giving him commands. He became socially isolated and dysfunctional as a result of these symptoms. He denies current drug use or medical problems. A menta status examination shows several abnormalities. Disturbances in grooming, hygiene and behavior (paranoia) are noted, he has a flat affect. His thought processes are occasionally loose and he reports auditory hallucinations and delusions. Most likely diagnosis: Schizophrenia, probably paranoid type Important Indication to rule out: To make a diagnosis of schizophrenia, psychosis secondary to substance abuse and general medical conditions must be ruled out. In addition, schizoaffective disorder, and mood disorder must also be excluded. Should this patient be hospitalized: Yes. He clearly poses a danger to himself (and potentially to others based on the nature of bad things he is being commanded to perform) because he listens to the voices and acts on their instructions so as to put himself at risk for serious physical harm (i.e., sitting in the middle of a busy street). Assignment No. 4 Concept on Gender Identity Disorder A 26 year old chromosomal male dressed as a woman comes to see a psychiatric a part of the work up required before he is allowed to have the sex change operation that he desires. He tells the psychiatrist that he has always felt he is a girl. He says, When I was born, there must have been some mistake. I should have had the

Summary: A 27 year old man presents to the emergency department with the classic signs and symptoms of mania. He has been abusing alcohol, but he abuse appears to have started after the onset of his manic symptoms. Whether he uses drugs is unknown and thus must be ruled out before a diagnosis of mania can be definitively established Next diagnostic step: A urinalysis for drugs of abuse should be ordered a determination of alcohol blood level should be made as well Most likely diagnosis: Bipolar disorder, manic Best initial treatment: Admission to the hospital should be recommended, although it is unclear whether the patient is committable at this point. At the least, he will need treatment with a mood stabilizer (lithium, carbamazephine, valproic acid) and perhapst with an antipsychotic (such as risperidone) as well.

Assignment No. 3 Concept on Schizophrenia A 21 year old man is brought to the emergency department by the police after he was found sitting in the middle of a busy street. By way of explanation, the patient states, The voices told me to do it, The patient says that for the past year he has felt that people are not who they are, He began to isolate himself in his room and dropped out of school. He claims that he hears voices telling him to do bad things. There are often two or three voices talking and they often comment to each other on his behavior. He denies that he currently uses drugs, or alcohol, although he reports that he occasionally smoked marijuana in the past. He says that he has discontinued this practice this practice over the past 6 months because it makes the voices louder,. He denies any medical problems and is taking no medication. On a mental status examination, the patient is noted to be dirty and disheveled, with poor hygiene. He appears somewhat nervous in his surroundings and paces around the examination room, always with his back to a wall. He states that his mood is Okay. His affect is congruent, although flat. His speech is of

body of a girl. Then, he notes that as a child he enjoyed playing with dolls and female playmates; he never seemed to fit in with those of his own male gender. He claims that he has adopted all the mannerism of a woman, including dressing like one, since leaving home at age 16. He states that he always would have dressed this way but was forbidden to do so by his parents, from whom he is now estranged. He admits that he has had no sexual experiences with women. His first sexual encounter with a man occurred when he was 18 years old, and he is currently in a relationship with another man lasting for the past 4 years. He considers himself a straight woman and has never seen himself as gay man. On his mental status examination, the patient appears alert and oriented to person, place and time. He is dressed in a blouse, skirt, jacket, nylons and high heels and purports himself to be a woman. His grooming is good and he cooperates fully during the examination. No abnormalities were found on his mental status examination. Questions: 1. Considering the manifestation, is there any emergent problem seen? If so, what is the danger and what should be done to prevent complications? 2. What is the most likely diagnosis to the case given above? 3. What are the possible nursing diagnoses manifested to the case given above? 4. What is the best treatment for the patient? 5. Create a Care Map Summary: A 26 year old man is referred to a psychiatrist as part of the work up for a sex change operation. He has a strong, persistent desire to be female and has dressed as woman since age 16. His sexual experiences have been exclusively with men. The results of his mental status examination are normal. Most likely diagnosis: Gender identity disorder Options other than sex reassignment surgery: Patients can take estrogen to create breasts and other feminine contours and undergo electrolysis to remove their male hair.