Please reply to the 2 peer posts using APA format

Post 1

1. Discuss the amygdala’s role in anxiety.
2. Compare and contrast how fear and worry are thought to be regulated. 
3. Based on any required lecture material in Module 5, write two possible quiz/exam questions. You may write multiple choice questions or short essay questions. Please include the answer, a rationale, and the source. The questions should be appropriately challenging and must be original (you may not use questions that are on NEI’s website or located online)

The Amygdala’s Role of and Regulation of Anxiety

The amygdala has connections, anatomically, that permit integration of sensory and cognitive information, provoking a fear response when determined appropriate (Stahl, 2021). According to lecture material (NKU, 2024), the amygdala has arousal receptors which increase CREB in the nucleus via norepinephrine and dopamine, as well as glutamate stimulating CREB in the central nuclei of the amygdala. Emotional regulation areas of the prefrontal cortex, specifically the orbitofrontal cortex and the anterior cingulate cortex are thought to have reciprocal connections that regulate fear and stimulate endocrine reactions, secondary to connectivity with the hypothalamus, leading to changes in the hypothalamic-pituitary-adrenal (HPA) axis triggering cortisol level changes (Stahl, 2021). Anxiety is a normal emotional response to fear, however, in excess, fear and anxiety become the core symptoms of anxiety disorders (Stahl, 2021). Chronic levels of elevated cortisol brought on by serial threats, such as those in adverse childhood experiences, are associated with significant comorbidities of impairments in social functioning and mental health (Tzouvara, 2023) as well as physical health, such as coronary artery disease, type 2 diabetes and stroke (Stahl, 2021). The autonomic nervous system responds to fear with responses in cardiovascular responses mediated by pathways between the amygdala and the locus coeruleus (Stahl, 2021). Chronic and inappropriate or serial triggering, as such in anxiety, can lead to these medical comorbidities and anxiety can also be triggered by memories held in the hippocampus and triggered by connectivity with the amygdala, such as the instance of PTSD (Stahl, 2021). The processing of these fear responses is regulated by specific neurotransmitters working with the amygdala, that include GABA, dopamine and serotonin, as well as voltage gated calcium channels.

Worry

            Worry is the other core symptoms in anxiety disorders thought to be secondary to malfunction of the cortico-striato-thalomo-cortical loops (CSTC) of the prefrontal cortex, mediated by GABA, serotonin, norepinephrine, glutamate, dopamine, and voltage-gated calcium ion channels, resulting in anxious misery, catastrophic thinking, obsessions, and apprehensive expectations. These regulating neurotransmitters overlap with those known to modulate the amygdala (Stahl, 2021).

Questions

• Comorbid symptoms in major depressive disorder (MDD) and several anxiety disorders are:

1. Sleep disturbances and fatigue
2. Concentration
3. Psychomotor arousal
4. All of the above

The correct answer is all of the above (NKU, 2024). There are many overlapping qualities such as the neurotransmitters and networks involved, in addition to the noted symptoms (Stahl, 2021).

• Age of onset risk of Anxiety in children is

1. 4-6 years of age
2. 6-12 years of age
3. 10-14 years of age
4. >12 years of age

The correct answer is 6-12, as noted in lecture materials (NKU, 2024).

References

Northern Kentucky University. (2024). MSN 671 Psychopharmacology, Module 5 Lecture Material.

Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th ed.). Cambridge University Press.

Tzouvara, V., Kupdere, P., Wilson, K., Matthews, L., Simpson, A., & Foye, U. (2023). Adverse childhood experiences, mental health, and social functioning: A scoping review of the literature. Child abuse & neglect, 139, 106092. https://doi.org/10.1016/j.chiabu.2023.106092

Post 2

Discuss the amygdala’s role in anxiety.

There are two core symptoms of anxiety, fear and worry (Stahl et al., 2021 p. 364).  Fear is controlled by the amygdala, a limbic structure that is a principal neural circuit thought to regulate anxiety (Nuss, 2015).  Imaging studies on humans has shown electrical stimulation of the amygdala leads to fear and anxiety (Nuss, 2015).  Additionally, functional imagery studies found the amygdala was activated in response to stimuli in patients with anxiety disorders more than non-anxious controls (Nuss, 2015). 

The amygdala is divided into two structures, the basal lateral amygdala complex (BLA) and central medial amygdala complex (Nuss, 2015). Negative stimuli are received into the BLA, from the thalamus, which activates the central medial amygdala complex through the release of glutamatergic pathway while also activating inhibitory GABAergic interneurons (Nuss, 2015).  This creates the affect of anxiety.  Normal anxiety responses stimulate motor responses such as fight or flight, release cortisol, and increase breathing (Stahl et al., 2021 p.364 – 365).

Compare and contrast how fear and worry are thought to be regulated.

Fear and worry are the two main symptoms associated with anxiety.  Fear is regulated through the amygdala, whose neurobiological regulators are GABA, serotonin, norepinephrine, and voltage calcium ion channels (Stahl et al., 2021, p. 364 – 365). Worry is regulated by the cortico-striato-thalamo-cortical circuit, whose neurobiological regulators are GABA, serotonin, dopamine, norepinephrine, glutamate, and voltage gated ion channels (Stahl et al., 2021, p.365 – 367). There is overlap in the neurotransmitters that regulate both systems.  Overlap of the neurotransmitters may cause excitability or dysfunction to a stimulus.   Malfunctioning of the amygdala-centered circuits can cause symptoms of anxiety and fear while malfunctioning of the cortico-striato-thalamo-cortical circuits can cause symptoms of worry, such as anxious fear, apprehensive expectations, and obsessions (Stahl et al., 2021, p364 – 367)

1. What other disorder’s symptoms, circuits, and neurotransmitters overlap with anxiety disorders?
2. Schizophrenia
3. ADHD
4. Dementia
5. Major Depressive Disorder

Answer:  D, major depressive disorder.  Fatigue, sleep difficulties, problems concentrating, and psychomotor symptoms are common with both anxiety disorders and major depressive disorders, which can increase the risk of misdiagnosing.  However, core symptoms are not the same and when assessing a patient, it is important to ensure the core symptoms associate with the diagnosis prescribed (Stahl et al., 2021 p. 360-361).

1. What is the best way to identify unipolar from bipolar?
   1. Obtain a family and social history
   2. Prescribe an SSRI
   3. Refer to a therapist
   4. Prescribe lithium

Answer: A, obtain a family and social history.  There is no good way to identify between unipolar and bipolar, however, a thorough clinical history can help make the diagnosis easier.  Stahl et al. (2021) suggest asking two questions “ who’s your daddy?”, meaning what is your family history, and “where’s your momma” meaning additional history will need to be obtained from someone close to the patient.

Philippe Nuss (2015) Anxiety disorders and GABA neurotransmission: a disturbance of modulation, Neuropsychiatric Disease and Treatment, , 165-175, DOI: 10.2147/ NDT.S58841

Stahl, S. M., Grady, M. M., & Muntner, N. (2021). Chemical Neurotransmission. In Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (pp. 224-282, pp. 359-378). Cambridge University Press.

Please reply to these 2 post with a short paragraph and 1 source for siting

Post 1:

Differential diagnosis

Prompt:

1. Jenn’s eight-year-old niece comes in with a sore throat and fever. What is your differential diagnosis? What assessments and tests would you perform and why?

Diagnosis: Pharyngitis (Strep throat), rheumatic fever, Covid

Questions for patient and aunt:

When did the pain start?

How long has this been occurring?

What does the pain feel like?

How bad is the pain? Use Wong-baker pain scale

When did the fever start?

How high did the fever get?

Does the patient attend school?

Any outbreak of strep in school?

Any sick contacts in the home or anyone positive for strep in the home?

Medications given for fever?

What have they tried to soothe the sore throat? What helps?

How is her appetite?

Any chills?

Any other sick symptoms? Cough? Congestion?

Has she ever had strep throat before?

Has Tylenol/Motrin helped the fever? (if applicable)

When did she last have medicine? (if applicable)

Has she ever had scarlet fever before?

Any redness or white patches in mouth?

Trouble swallowing?

Pain with swallowing?

Any joint pain?

Fatigue?

Recent travel?

N/V?

Hoarseness?

Runny nose?

Headaches?

Allergies?

Has she ever been prescribed antibiotics?

Is it okay if I start your assessment?

Labs:

Rapid Strep and PCR strep test

Rapid Covid

EKG (if applicable)

Assessment/Intervention:

Non-meds

Inspection of breathing, posture, and general appearance. Full set of vital signs including height and weight. These measurements will assist with pharmacological interventions as well as comparing prior measurements to indicate weight changes or malnutrition.  Auscultate breath sounds to assess for wheezing, diminished lung sounds or crackles indicating congestion, fluid or narrowing airway. Auscultate heart sounds for any adventitious sounds such as murmurs or friction rub. Assess the tongue for color, texture, bumps, strawberry appearance, moisture, and dryness. Assess mouth for white or red patches, tonsils for swelling, hard and soft palates; have patient stick out tongue and say “ah”. Assess skin turgor for tenting to indicate dehydration; also assess skin for any visible lesions or masses. Inspect ear canal for tympanic membrane, absence of drainage, absence of bulging and color of canal. Palpate head, lymph nodes and sinuses for tenderness and swelling. Assess for Jones criteria.

Meds

Amoxicillin 500 mg bid x 10 days

Tylenol q 6 for fevers >100.4

Motrin q 8 for fevers >100.4

Education:

Discard toothbrush after 48 hours of starting antibiotic

Call PCP if symptoms do not improve in 3-4 days of antibiotic use

Cold liquids and popsicles to soothe throat

Use vaporizer in room when resting

Warm tea or soup

Rest

School note to return to school when fever free and after antibiotics for 24-48 hours for pharyngitis

Can return to school when fever free and per CDC isolation guidelines for Covid

1. Jenn’s 10-year-old niece vomits every morning before school. What additional assessments would you perform, and what might you discuss with her? Why?

The assessments that I would like to perform for this patient would be a mental health assessment and physical assessment. Due to the patient being under the age of 12 to conduct a GAD assessment, this NP student would ask the patient interview questions to get a better understanding of her symptoms to decipher its relativity to mental or physical well-being. I would perform a cardiac, lung, neurological and abdominal assessment on this patient.

Authors state that “youth with social anxiety disorder often begin life with behavioral inhibition, and go on to experience full onset of anxiety symptoms near age 12. Children with social anxiety disorder are self-conscious and experience intense anxiety in social situations, worry about embarrassing themselves and fearing negative evaluation by peers or others.” They go on to discuss how social anxiety can cause school avoidance in pediatric and adolescent children (Strawn, et. al, 2021).

Questions:

Does anything help prevent you from vomiting?

When are you most calm and happy?

What subjects do you have in school?

What is your most favorite and least favorite subject in school? Which one is first bell?

Do you play any sports?

Are your teachers nice?

Do you have friends that attend your school?

Experienced bullying?

Do you eat breakfast at school?

When is bedtime?

Do you awake at night during the school week?

What time do you wake up for school?

Tell me about your morning routine?

How do you get to school; are you a car rider or do you catch the bus?

How are you in the summer in the mornings and on weekends?

Any siblings? Do they attend school with you?

Does your school have a school counselor?

Do you eat breakfast and lunch at school? Who do you sit with?

Trouble focusing in class?

Do you wear glasses?

Where do you sit in your classroom; near the board, back of room or in the middle?

Tell me about your grades

Any trouble urinating? Frequency?

Any trouble with bowel movements? How often?

Any trouble with speech?

Any belly pain?

What color is the emesis?

How often do you drink water or sugary drinks?

How often do you eat meals with family?

Do you do at least 1 hour of active exercise daily?

Do you have a tv in your bedroom?

How often do you use electronics?

Any weakness?

Any shortness of breath or palpitations?

Any dizziness?

Intervention:

Consult with PCP for concerns for anxiety

Encourage waking up early enough to eat a light morning snack or breakfast

Toileting before school starts if needed

Zofran p.o PRN in morning before school if applicable

OT: occupational therapy referral to CCHMC for possible anxiety disorder if diagnosed

Encourage guardian to seek school counseling for patient if indicated

Depending on severity and if it is affecting school performance may need to look into 504 plan

Post 2:

Dr. Jenn’s uncle is now 68 years old and has smoked one and a half packs of cigarettes every day since he was fifteen. How many “pack-years” should be reported? What would you expect to find in his respiratory assessment? How would this affect your oxygenation goals for this patient?

The patient has 79.5 pack years smoking history (1.5 packs per day x (68-15) = 79.5) (Ball et al., 2023). The patient’s substantial history of smoking would lead this student to believe that there would be findings in his physical assessment suggestive of chronic obstructive pulmonary disease (COPD) which is an irreversible expiratory airflow obstruction. Inspection may reveal accessory muscle usage, audible wheezes, cyanosis, and distention of neck veins (when right-sided heart failure is present) (Ball et al., 2023). Palpation may exhibit diminished vocal fremitus in patients with COPD, but this is usually saw in patients that exhibit barrel chest (Ball et al., 2023). Percussion can display hyperresonance related to hyperinflation of the lungs (Ball et al., 2023). Auscultation can reveal rhonchi, sibilant wheezing, inspirations crackles, and diminished breath sounds particularly in the lower lobes (Ball et al., 2023). The damage that has occurred to the patient at this point is irreversible but the main goal for this patient is for him to engage in a tobacco cessation program to prevent further lung damage. Often these patients struggle with dyspnea which affects numerous aspects in their life from completion of activities of daily living to sleep disturbances and weight loss (Vogelmeier et al., 2020). COPD can also result in muscle deconditioning due to decrease activity related to dyspnea, this muscle deconditioning can further exacerbate their dyspnea (Vogelmeier et al., 2020). Dietician referrals should be made to assess nutrition status and for the dietician to offer recommendations to maintain their weight; often finger foods are easier for these patients. The biggest goal that we should discuss with our patient is activity modifications to prevent dyspnea and exacerbations, avoiding crowds and ill people as they are more susceptible to respiratory illness and virus, and lastly maintaining the health status that they have in terms of activity and nutrition; these three major goals will assist in maintain our overall oxygenation goal for this patient (Vogelmeier et al., 2020).

Dr. Jenn’s 68-year-old aunt struggles with controlling her hypertension and high cholesterol. What concerns might you have concerning her body systems, and how would this change your assessment? What teaching points would you review with Dr. Jenn’s aunt?

Initially the concerns that I would have related to her body systems would be her cardiovascular system, renal system, liver, and eyes. The reason that the cardiovascular system would be a concern to this student would be related to right sided heart failure, for this assessment this student would focus on assessing for JVD, peripheral edema, pitting edema, weight gain, and hepatomegaly (Ball et al., 2023). Further assessment questions that would be asked would be related to shortness of breath at rest, on exertion, and orthopnea. The renal system would be of concern due to the constriction of blood vessels to the kidneys which can result in damage to the kidneys (Ball et al., 2023). Assessment of the kidneys would include history on urination habits compared to intake, weight gain, edema, and lung sounds for signs and symptoms of possible fluid overload such as crackles. Diagnostic studies such as a complete metabolic panel. Obesity, hyperlipidemia, smoking, and hypertension will all increase the patient’s risk of developing Nonalcoholic Fatty Liver Disease therefore assessment of the liver should be completed (Ball et al., 2023). Liver assessment will involve percussion the liver margins, palpating for RUQ pain, jaundice, a thorough history of patient’s complaints of fatigue, malaise, and diagnostic studies such as AST and ALT. The reason for the concern for the eyes would be that uncontrolled hypertension can lead to papilledema and/or cotton wool spots which would be assessed for during the ophthalmoscopy exam (Ball et al., 2023).

The education for hypertension and hyperlipidemia will go hand in hand since they both have similar modifiable risk factors. Teaching points would include a dietician/nutritionist referral and the necessity of this. If the patient does not wish to be referred to a dietician/nutritionist it is important to educate her on the needs of a lower cholesterol diet, lean protein such as fish and chicken, increased fruits, and vegetables, and avoiding saturated fats and fried foods. The patient would also need education on limiting sodium intake to prevent excess fluid retention and avoiding processed and fast foods. The patient should be educated and encouraged on regular physical activity for at least 30 minutes 5 times a week, physical activity has been shown to lower bad cholesterol numbers (HDL) (Nouh et al., 2019). The patient should also be educated on tobacco cessation (if applicable) as smoking can increase blood pressure and damage the walls of blood vessels making them more susceptible for fatty deposits (Nouh et al., 2019). We would need to understand the patient’s support system and the support that she will have at home while undertaking a new diet and exercise plan, if she has no support referrals should be made for community resources that may be available for support. Studies have shown that patients that participate in a multidisciplinary group class is an effective way to provide patient education for hypertension and patients also benefit from support received by peers experiencing similar disease states (Meredith et al., 2020). The patient will need education on the importance on compliance with medication regimen, what each medication is prescribed for, how and when to take the medications, and side effects that she may potentially see and when to seek medical attention for any adverse side effects. The patient will need education on taking her blood pressure and maintaining a log so that she can discuss trends with her primary care at future follow ups so that medications may be adjusted as needed. The patient will also need educated on when to seek medical attention should her blood pressure remain elevated at a certain parameter despite taking her medication or should her blood pressure remain low past a certain parameter. Lastly, we would want to reiterate the importance of why we are doing this; chronic hypertension and hyperlipidemia can increase the patient’s likelihood of myocardial infarctions, strokes, and heart failure, among other comorbidities if the patient is obese.

• You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts. 
• All replies must be constructive and use literature where possible. They must be at least 100 words and supported by at least one source. 

Reply 1:

Based on the patient’s history of available information, the diagnosis, in this case, is Clostridioides difficle (C.diff) associated diarrhea or infectious diarrhea. He recently started an antibiotic course of Ciprofloxacin BID for prostatitis; patients who are prescribed antibiotics risk getting C-diff as antibiotics can disrupt the normal intestinal flora, causing an overabundance of C. diff bacteria in the colon, causing diarrhea and colitis, which is an inflammation of the colon (Silva, 2020). Ciprofloxacin belongs to the fluoroquinolone class and is approved to treat prostatitis; it is the most potent against gram-negative bacilli bacteria (STATPearls, 2023). Diarrhea is a common side effect of different antibiotics such as Macrolides, Cephalosporins, Penicillin, and Fluoroquinolones (STATPearls, 2023).

The patient is susceptible to contracting C. diff due to his advanced age and autoimmune disorder. I would discuss with the patient the possibility of admitting him to the hospital. It will be safe to admit the patient since he can be better observed and treated. Also, this will eliminate the bacteria from spreading to the community and his wife. Concerning who will take care of his wife, since he is the primary caretaker, it will be best to involve a case worker or a social worker who can further assist in finding a helper to care for his wife while at the hospital.

 I would immediately stop the Ciprofloxacin and order a toxigenic culture stool test, a gold standard for detecting C-diff (Qutub et al., 2019) to rule out C-diff-related diarrhea. I would also order a regular stool test to rule out parasites or ova to narrow the diagnosis.

            This patient would also be assessed for any electrolyte imbalances. I would check for signs of dehydration, such as sunken eyes, parched lips, hypotension, and skin turgor. However, skin turgor is unreliable in elderly patients due to the loss of subcutaneous fat. Dehydration is common among older adults. Since this patient is hypotensive and mildly tachycardic, which are signs of dehydration, the writer would admit the patient as he elicits signs of dehydration. Elderly patients need a more cautious approach when ordering IV fluids.

After admitting the patient, I would order a Normal Saline Intravenous infusion (IV) of 100 ML /hour to rehydrate the patient. I would frequently reassess the patient and call additional boluses as needed. The patient’s blood pressure, heart rate, hematocrit, and urine output will be monitored to assess response to IV fluid and volume deficit before ordering an additional dose (Taylor and Jones, 2022).

I would discontinue Ciprofloxacin.

I would order a STAT comprehensive metabolic panel (CMP) test to explain his current fluid and electrolyte balance. The test will assist in knowing about his current potassium, sodium, and magnesium levels. This test will also help in knowing about his Bun and creatinine level since he has a history of hypertension and has been taking Lisinopril, Metoprolol, and Ibuprofen, which can negatively impact his renal system.

I will also order a complete blood count (CBC) since his WBC cells may be concurrently elevated due to the C-diff infection. I would hold on to his blood pressure medication for now as his blood pressure is trending on the lower side, and frequently recheck and reevaluate his status. I would also hold on to Ciprofloxacin until C. diff clears off.

If the stool test results return positive for C-diff, I would order Vancomycin, a tricyclic glycopeptide antibiotic for gram-positive bacteria approved for treating C-diff (STATPearls, 2023).

If the stool test is negative for C-diff, I will refer the patient to a gastrointestinal specialist to rule out if the patient has any GI problems. I would hold on to prescribing anti-diarrheal medication until the stool test results return. If the stool test results are negative for C. diff, I would start him on a different antibiotic and order anti-diarrheal medication such as Lomotil.

If the patient’s blood pressure stabilizes and he isn’t showing any signs of deterioration and having loose motions. Also, depending on how the patient responds to the treatment and the test results, he will be evaluated to see if he is medically stable to be discharged. The patient will be educated to remain compliant with the antibiotics and finish the course even if his symptoms improve. The patient will be educated on good hand-washing; using bleach products to wipe the areas and surfaces can help prevent the reoccurrence of C. diff.  

                                                                                                References

Silva, B. (2020, April 1). Detection and prevention of C. disinfections. Medical Laboratory Observer, 52(4).

Rahmoun, L. A., Azrad, M., & Peretz, A. (2021). Antibiotic Resistance and Biofilm Production Capacity in Clostridioides difficile. Frontiers in Cellular & Infection Microbiology, 11, 1–10. https://doi.org/10.3389/fcimb.2021.683464Links to an external site.

 STATPearls. (2023, March 7). Ciprofloxacin. STATPearls. Ciprofloxacin Article (statpearls.com)Links to an external site.

STATPearls. (2023, March, 24). Vancomycin. STATPearls. Vancomycin Article (statpearls.com)Links to an external site.

Qutub, M., Govindan, P., & Vattappillil, A. (2019). Effectiveness of a Two-Step Testing Algorithm for Reliable and Cost-Effective Detection of Clostridium difficile Infection in a Tertiary Care Hospital in Saudi Arabia. Medical Sciences, 7(1), 6–1. https://doi.org/10.3390/medsci7010006Links to an external site.

Taylor, K., & Jones, E. B. (2021). Adult dehydration. In StatPearls. StatPearls Publishing.

I would also like to add blackberry root to be discontinued for this patient.  After admitting him, I will put the patient on contact precaution. Centers for Disease Prevention and Precaution guidelines state to use contact precaution to prevent C-diff from spreading. The staff will follow the contact precaution guidelines while caring for this patient: gloves, gown, and washing with soap and water, as alcohol-based hand sanitizers do not completely kill the bacteria (CDC. 2021). 

 Reference:

Centers for Disease Control and Prevention. (2021, July 20). Prevent the Spread of C. diff. https://www.cdc.gov/cdiff/prevent.htmlLinks to an external site.

Reply 2:

Diagnosis: Clostridium difficile infection CDI.

The patient is 72 years old with a history of hypertension, hyperlipidemia, and rheumatoid arthritis. This patient has been taking Ciprofloxacin for the treatment of prostatitis. For the past two days, the patient has complained of frequent loose stools (4-5 stools). One regular well-formed stool daily bowel movement is the norm for this patient. This patient presents with multiple risk factors that would increase the risk of CDI. One major risk factor is the patient age of 72years and having diarrhea which can easily cause dehydration because the patient takes medication for hypertension (Metoprolol XR 25mg PO Daily and Lisinopril / HCTZ 10/12.5mg PO Daily) and is losing fluids due to diarrhea. According to Mayo Clinic (2022), there is a 10 times greater risk of patients who are 65 years and older developing CDI. Secondly, the patient also exercises daily with senior peers out in the community increasing susceptibility and exposure risk to highly contagious infections like CDI. Another major risk factor is that this patient has recently been on antibiotics (Ciprofloxacin) which can increase the risk of CDI. Ciprofloxacin belongs to the drug class Fluoroquinolones and is commonly associated with the development of CDI because they disrupt gut bacteria and make one susceptible to a higher risk of CDI (Mayo Clinic, 2022).

 Lab work and testing: The patient would need to be placed on isolation precautions at the Emergency Department while testing is done. The provider will order lab tests and stool samples for testing (Mayo Clinic, 2022). An antigen detection for C. diff detection and a PCR will be ordered, this is a rapid test that takes less than 1 hour to detect the presence of C. diff antigen glutamate dehydrogenase. Blood work will be tested for the patient for WBC, CBC, CMP, and serum creatinine to assess kidney failure associated with CDI.

Admission criteria: CDI can be categorized into three groups which could be non-severe, severe, or fulminant CDI.  Non-severe CDiff is treated with vancomycin and the patient can be discharged home in the care of a caregiver, severe cases with a WBC higher than 15,000 and a creatinine level higher than 1.5 indicating kidney impairment will need hospitalization for treatment and fluid intervention to prevent dehydration. Fulminant CDI can cause toxic megacolons, hypotension, shock and have a high fatality rate, and will require ICU intervention. Depending on the results of the labwork, and WBC, the provider will likely decide to admit the patient.

Treatment plan:

Discontinue the Ciprofloxacin based on findings from research indicating that exposure to fluoroquinolones including third and fourth-generation cephalosporins are known to increase the risk of CDI (CDC.gov, 2022). Studies done by the University of Illinois Chicago in 2021 indicate that treatment with fidaxomicin is preferred in place of Vancomycin due to the benefits and safety effects of fidaxomicin in the older population. Provider to prescribe 200mg of fidaxomicin by mouth to be taken by mouth twice daily for 10 days. Discontinue the Blackberry root and provide education on safe medication usage and the importance of completing the full 10-day course of prescribed antibiotics. Educate the patient on the risks of reinfection and the importance of adhering to the full dose of the prescribed antibiotic regimen, 1 in 6 persons with CDI is likely to get reinfected in 2 to 8 weeks (CDC.gov, 2022). Major risks for patients at this age with CDI are the risk of dehydration, kidney failure, toxic megacolon, and death (Mayo Clinic, 2021). This patient is reported to exercise daily with peers in the community center, there is a need for education for peers at the site where they exercise, and education on personal hygiene and especially hand hygiene will be emphasized for the patient, patient’s family, caregivers, and anyone in contact with the patient because CDI is highly contagious (CDC.gov. 2022).

Question to peers: How does the provider assess the effectiveness of education on completing the full course of the antibiotic regimen for Patient John D?

References:

C. difficile infection – Symptoms and causes. (2021, August 27). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/c-difficile/symptoms-causes/syc-20351691Links to an external site.

Guidelines and prevention resources for clinicians. (2022, September 7). Centers for Disease Control and Prevention. https://www.cdc.gov/cdiff/clinicians/resources.htmlLinks to an external site.

What are the 2021 guideline updates on the management of Clostridioides difficile infection (CDI) in adults? | Drug Information Group | University of Illinois Chicago (uic.edu)Links to an external site.