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Assignment: Assessing and Diagnosing Patients With Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders

NRNP 6635 Assignment: Assessing and Diagnosing Patients With Schizophrenia, Other Psychotic Disorders, and Medication-Induced Movement Disorders

Subjective:

CC (chief complaint): ‘I have problems in my workplace.’

HPI: Ms. Branning is a Twenty Five yearold woman who came to the clinic after Mr. Nehring her boss, suggested she should go for a Psychiatric evaluation. Ms. Branning reports having problems in her workplace. According to her, Mr. Nehring, her supervisor wants to fire her because Eric is in love with her. Eric is her supervisor who she feels is attracted to her. Ms. Branning is not in a relationship with Eric but believes that she is beautiful and people, including Eric are attracted to her. Ms. Branning feels that Nehring is jealous of her, as she thinks she  could replace him in a couple of years. According to her, she has mental problems that have been worsening over time. She reports having pain in the neck and broken heart, which are probably attributed to cancer.

Past Psychiatric History:

  • General Statement: ‘I have problems in my workplace.’
  • Caregivers (if applicable): self
  • Hospitalizations: no index of hospitalizations
  • Medication trials: no index of medication trials
  • Psychotherapy or Previous Psychiatric Diagnosis: no indication of previous psychotherapy or psychiatric diagnosis.

Substance Current Use and History: None indicated.

Family Psychiatric/Substance Use History: Mrs. Branning denied any history of psychiatric conditions or substance use in her family.

Psychosocial History: The client is single and in a relationship. She lives with her family. She has two brothers who are alive. She is a Christian. She reports to seek support from her family members in times of hardships.

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Medical History: Mrs. Branning denied any history of hospitalization, surgery or blood transfusion.

 

  • Current Medications: Levothyroxine daily
  • Allergies: Medical Tape
  • Reproductive Hx: Mrs. Branning reported that her last menstrual period was 3/10/2021. She has regularmenstrual cycle of 28 days lasting for four days. She is currently on a contraceptive method. She denied history of sexually transmitted infections. She also denied history of multiple sex partners. She does not have any history of pregnancy loss.

ROS:

GENERAL: The client appears appropriately dressed for the occasion. There is the absence of observable fatigue or evidence of weight loss.

HEENT: Eyes: she denies visual loss, blurred vision, double vision, or eye drainage.

Ears, Nose, Throat: She denies hearing loss, ear drainage, sneezing, congestion, runny nose, or sore throat.

SKIN: She denies rash or itching.

CARDIOVASCULAR: She denies chest pain, chest pressure, or chest discomfort. No palpitations and presence of lower limbs edema

RESPIRATORY: She denies shortness of breath, cough, or sputum.

GASTROINTESTINAL: She denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or passage of blood stained stool

GENITOURINARY: She denies burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: She denies headache, denies dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control

MUSCULOSKELETAL: She denies joint pains and edema

HEMATOLOGIC: She denies changes in skin color due to bleeding under skin

LYMPHATICS: She denies enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: She denies reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Objective:

Physical exam:

Temp 98.4F RR 18 HR 80 BP 127/68 SPO2 98% Weight 52 kgs Height 152 cm BMI 22.5

GENERAL: She is well groomed for the clinical visit, with no evidences fatigue nor weight loss

HEENT: Eyes: Normal vision acuity and accommodation, absence of double vision, and jaundice or eye drainage.

Ears, Nose, Throat: Normal air and bone conductivity, absence of nasal flaring, ear discharge, loss of balance, rhinorrhea, or deviation of nasal septum

SKIN: Absence of petechie, cyanosis and skin rashes

CARDIOVASCULAR: Absence of adventitious sounds on palpation and breathing using accessory muscles and chest in drawing

RESPIRATORY: Absence of cough, sneezing, sputum, and adventitious sounds on auscultation

GASTROINTESTINAL: Absence of abdominal masses, scars, and abnormal bowel sounds

GENITOURINARY: Not examined

NEUROLOGICAL: Absence of paralysis, ataxia, numbness, or tingling in the extremities, changes in bowel and bladder control and level of consciousness.

MUSCULOSKELETAL: Absence of joint pains, edema, and restricted movement in a range of motions

HEMATOLOGIC: Absence of  bleeding and anemia

LYMPHATICS: No enlarged nodes

Diagnostic results: The complaints that Ms. Branning do not require any diagnostic investigations. History taking and physical examination can provide data for use in making an accurate diagnosis to guide the treatment. However, blood tests can be performed to determine if the patient has other underlying conditions such as an infection. Besides, chest x-ray may be ordered to determine if the client has chest or respiratory problems causing the symptoms.

Assessment:

Mental Status Examination: Ms. Branning is appropriately dressed for the occasion. She does not show any signs and symptoms of fatigue or weight loss. She is oriented to self, place, time and events. Her insight is normal. She reports delusional behaviors. She denies illusions and delusions. She denies suicidal thoughts, attempts and plans. Her thought content is future oriented.

Differential Diagnoses:

Erotomania with somatic disorder: The primary diagnosis for Ms. Branning is erotomania with somatic disorder. Erotomania is a mental disorder where a patient believes that another individual is in love with them. The individual is always someone who is famous or important. The patient may engage in behaviors such as stalking and trying to contact the delusional object to satisfy their needs. Patients with somatic disorder believe that they have a chronic condition or physical defect. The believe is false, as medical and diagnostic tests are always normal (Coltheart & Langdon, 2019; Faden et al., 2017). Ms. Branning has erotomania with somatic disorder, as she believes that Eric loves her and thinks she has cancer.

Grandiose disorder:The secondary diagnosis to be considered for the client is grandiose disorder. Patients with grandiose disorder have an inflated sense of esteem and self-worth. They believe that they have a superior self-identity to others (Isham et al., 2021). Ms. Branning is likely to be diagnosed with this disorder, as she believes that she is the most beautiful woman in the organization. As a result, people are attracted and envious of her.

Persecutory deluson: The other secondary diagnosis to consider is persecutory delusion. Patients with persecutory delusions often feel that others want to harm them. They also feel that others want to mistreat or spying against them (Diaconescu et al., 2019; Murphy et al., 2018). Ms. Branning may be diagnosed with this disorder because she thinks that Mr. Nehring wants to fire her because he thinks that Eric loves her. Therefore, the differentials should be considered in treating the patient.

Reflections:I agree with the diagnosis of the patient with erotomania and somatic disorder. She has symptoms that most align with the disorders. I have learned from this experience that delusional disorders exist in different types. Psychiatric mental health nurse practitioner should have the knowledge and skills to develop accurate diagnoses and treatment plans for their patients. One of the things that I would do in the future is intiating the client on psychotherapy sessions to equip her with skills for managing intrusive symptoms of the disorder.

References

Coltheart, M., & Langdon, R. (2019). Somatic delusions as motivated beliefs? Australian & New Zealand Journal of Psychiatry, 53(1), 83–84. https://doi.org/10.1177/0004867418815981

Diaconescu, A. O., Hauke, D. J., & Borgwardt, S. (2019). Models of persecutory delusions: A mechanistic insight into the early stages of psychosis. Molecular Psychiatry, 24(9), 1258–1267. https://doi.org/10.1038/s41380-019-0427-z

Faden, J., Levin, J., Mistry, R., & Wang, J. (2017). Delusional Disorder, Erotomanic Type, Exacerbated by Social Media Use. Case Reports in Psychiatry, 2017, e8652524. https://doi.org/10.1155/2017/8652524

Isham, L., Griffith, L., Boylan, A.-M., Hicks, A., Wilson, N., Byrne, R., Sheaves, B., Bentall, R. P., & Freeman, D. (2021). Understanding, treating, and renaming grandiose delusions: A qualitative study. Psychology and Psychotherapy: Theory, Research and Practice, 94(1), 119–140. https://doi.org/10.1111/papt.12260

Murphy, P., Bentall, R. P., Freeman, D., O’Rourke, S., & Hutton, P. (2018). The paranoia as defence model of persecutory delusions: A systematic review and meta-analysis. The Lancet Psychiatry, 5(11), 913–929. https://doi.org/10.1016/S2215-0366(18)30339-0

 

Subjective:

CC (chief complaint): “My parents requested this appointment.”

HPI: Jay Feldman is a 19-year-old European-American male client on psychotherapy after his parents booked him a psychiatric appointment. When booking the appointment, Feldman’s parents reported that he was having difficulties in school. However, the client states that he is doing fine in school as a freshman pursuing Theoretical physics and advanced calculus. Feldman mentions that the combined courses are mysteries, and the moment he thinks that he has grasped it, it fades away. The client mentions that his roommate at State College brought a microwave. He reports that the purpose of the microwave is to trigger a bleeding degeneration of blood cells and bleed humanity from peoples’ rightful destiny. Feldman also mentions that their room is spying on them. The client has not been showering.

Past Psychiatric History:

  • General Statement: The client has a psychiatric history of mild paranoia.
  • Caregivers (if applicable): None
  • Hospitalizations: None
  • Medication trials: The patient was on a short trial of Aripiprazole for six months. The medication was stopped due to the side effects of akathisia.
  • Psychotherapy or Previous Psychiatric Diagnosis: Mild paranoia

Substance Current Use and History: Attempted to smoke marijuana twice at 18 years. He admits to taking vodka 3-4 glasses on weekends. Denies tobacco or other illicit substance use.

Family Psychiatric/Substance Use History: The patient has two younger brothers; one has a history of ADHD and the other a history of anxiety. Feldman’s mother has a history of anxiety, and his father of paranoia schizophrenia.

Psychosocial History:  Feldman is a freshman at State College pursuing a combination of Theoretical physics and Advanced calculus. He plans to pursue a double major in philosophy and physics. He is the firstborn in a family of three and was raised by both parents. He attained all his childhood developmental milestones. He states that he has several friends, but he has not kept in touch with them since he came back home. He sleeps 4–5 hrs per day.

 

Medical History:

 

  • Current Medications: None
  • Allergies: None
  • Reproductive Hx: No history of STIs.

ROS:

  • GENERAL: Reports appetite loss and weight loss. Denies fever, chills, or increased fatigue.
  • HEENT: Denies visual changes, ear pain/discharge, rhinorrhea, or swallowing difficulties.
  • SKIN: Denies rashes, discoloration, or bruises
  • CARDIOVASCULAR: Denies dyspnea, neck distension, or edema.
  • RESPIRATORY: Denies SOB, wheezing, or productive cough.
  • GASTROINTESTINAL: Reports having an inconsistent appetite. Denies having nausea, vomiting, abdominal discomfort, diarrhea, or constipation.
  • GENITOURINARY: Denies urinary symptoms.
  • NEUROLOGICAL: Denies headache, dizziness, or muscle weakness.
  • MUSCULOSKELETAL: Denies joint stiffness/pain or muscle pain.
  • HEMATOLOGIC: Denies bruising.
  • LYMPHATICS: Denies swollen lymph nodes.
  • ENDOCRINOLOGIC: Denies excessive sweating, heat/cold intolerance, or acute thirst.

Objective:

Physical exam: T- 98.3 P- 69 R 16 106/72 Ht 5’7 Wt 117lbs

Diagnostic results: None

Assessment:

Mental Status Examination:

The patient is untidy with shaggy hair, long dirty nails, yellow teeth, and a stinking body odor. He is alert but appears fatigued. He maintains minimal eye contact and appears uninterested in the interview. His speech is clear but speaks at a fast rate and high volume. The self-reported mood is “okay,” but he has a flat affect. He makes long pauses before responding to questions. He has a looseness of association, and his speech is difficult to follow. His thoughts are disorganized. The client has odd beliefs and paranoid delusions. No hallucinations, phobias, compulsions, or suicidal/homicidal ideations were noted. Insight is absent.

Differential Diagnoses:

Schizophrenia: Schizophrenia is a psychotic disorder characterized by hallucinations, delusions, and problems with perception, thought, and behavior. The DSM-V criteria for diagnosing schizophrenia require the presence of two or more of the following psychotic features: Delusions, Hallucinations, Disorganized or catatonic behavior, Disorganized speech and Negative symptoms (McCutcheon et al., 2020). Schizophrenia is thus a differential diagnosis based on the patient’s symptoms of odd beliefs, paranoia delusions, looseness of association, and disorganized thoughts and speech. The patient’s symptoms have contributed to impairment in academic and self-care activities.

Bipolar Disorder: Bipolar disorder is diagnosed based on the presence of alternating episodes of mania and profound depression. Mania is manifests with an elevated/irritable mood and increased goal-directed activity. Patients also present with grandiosity, excessive talking, racing thoughts, distractibility, diminished need for sleep, and increased engagement in risky activities (McIntyre et al., 2020). The episodes of profound depression present with a depressed mood, loss of interest, insomnia/hypersomnia, appetite changes, and suicidal ideations (McIntyre et al., 2020). Bipolar disorder is a differential based on the patient’s symptoms of looseness of association, reduced sleep, inconsistent appetite, and altered functioning in school and self-care areas. Nonetheless, the patient has no history of depression which makes Bipolar disorder an unlikely primary diagnosis.

Persecutory Delusional Disorder (PDD): Patients with PDD present with a persistent pattern of unwarrantable distrust and suspicion of others. They interpret others’ motives and actions as spiteful. Besides, individuals perceive that they may be attacked at any time and without reason (González-Rodríguez & Seeman, 2020). The patient’s paranoid delusions are consistent with PPD. The client believes that his roommate has brought a microwave to cause a bleeding degeneration of blood cells and bleed humanity from peoples’ rightful destiny. Besides, he expresses suspicions that they are being spied on in their room. However, the patient has looseness of association, and disorganized thoughts and speech, which are not characteristic of PPD, making it an unlikely primary diagnosis (Joseph & Siddiqui, 2021).

Reflections:

If I were to redo the session, I would assess the patient for depressive and anxiety symptoms, common comorbidities of schizophrenia. I would assess anxiety and depression using screening tools such as the Generalized Anxiety Disorder Assessment (GAD-7) and Patient Health Questionnaire- 9 (PHQ-9). The tools are effective in identifying the symptoms and their severity. Ethical principles to be considered in this patient include beneficence which is a duty to promote good and thus the best patient outcomes (Bipeta, 2019). Nonmaleficence should also be considered by avoiding causing harm to the patient. Health promotion interventions should include educating the patient on lifestyle changes such as increasing the level of physical activity and practicing healthy dietary habits.

 

References

Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19

González-Rodríguez, A., & Seeman, M. V. (2020). Addressing Delusions in Women and Men with Delusional Disorder: Key Points for Clinical Management. International Journal of Environmental Research and Public Health17(12), 4583.

Joseph, S. M., & Siddiqui, W. (2021). Delusional Disorder. In StatPearls. StatPearls Publishing.

McCutcheon, R. A., Reis Marques, T., & Howes, O. D. (2020). Schizophrenia-An Overview. JAMA Psychiatry77(2), 201–210. https://doi.org/10.1001/jamapsychiatry.2019.3360

McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L. V., Malhi, G. S., Nierenberg, A. A., Rosenblat, J. D., Majeed, A., Vieta, E., Vinberg, M., Young, A. H., & Mansur, R. B. (2020). Bipolar disorders. Lancet (London, England), 396(10265), 1841–1856. https://doi.org/10.1016/S0140-6736(20)31544-0

 

Subjective:

Chief Complaint: “Mr. Nehring suggested you see me. He said you are having some issues at work ”

History of Presenting Illness: F.B is a 27-year-old Caucasian female presenting for a psychiatric evaluation as recommended by her supervisor following allegations of issues at her workplace. She has a medical history of scoliosis and is currently under chiropractic care. She currently works as an administrative assistant in car sales. She lives alone and is an only child. She has had issues at her workplace. She has not been able to make any sales in three weeks. She feels that her supervisor is in love with her even though he has not done anything inappropriate. The supervisor has a girlfriend. F.B feels like her boss and her supervisor are ganging up against her to persecute her by firing her. She also believes that her boss is threatened by her being a strong woman who may replace him in his position. She also reports feeling pain in her neck that radiates to her back and thinks there is a lump on her back. She thinks this could be cancer. She believes that the ‘cancer’ is slowly killing her due to her supervisor’s obsession with her. She declines consultation with parents for collaborative history.

Past Psychiatric History: F.B’s past psychiatric history is unknown as she has declined to discuss her past psychiatric history and she also declined to consult with patients for a collaborative history.

Substance Current Use and History: FB reports no history of alcohol use or any substance abuse.

Family History: There is no mention of any history of psychiatric illness in the family. F.B’s family history is unclear as she has not disclosed much information about her family. There is no mention of a family history of diabetes, hypertension, cancer, or mental illness.

Social History: F.B was raised by her parents. She is an only child. She lives in Coronado. She lives alone. She has a Bachelor’s degree in hospitality. works as an administrative assistant in car sales. There is no reported history of trauma or violence in her life.

Medical History:

She has a medical history of scoliosis under treatment with chiropractic care.

  • Current Medications: F.B has no current medications. She is only under chiropractic care for managing scoliosis.
  • Allergies: She reports being allergic to latex, and no food or drug allergies were reported.
  • Reproductive History: F.B does not mention if she has borne any children, she has regular menses, she has no history of the use of contraceptives, and she has no history of treatment for any STIs. She practices vaginal intercourse.

ROS:

GENERAL: no weight loss reported, no fever, and no feeling of lethargy

  • HEENT: The head is of normal size, no obvious masses, normal hair distribution, no headache, the eyes are placed normally, no visual disturbances, no eye pain, no scleral jaundice, no conjunctival pallor, the ears are anatomically normal, no cerumen impaction, no auditory disturbances, No neck masses, no nasal congestion, or sore throat reported
  • Skin: No skin color changes, no swellings, no striae.
  • Cardiovascular: there is no edema of the extremities, no awareness of heartbeat, no dyspnea on exertion or orthopnea, there is no distention of the neck veins.
  • Respiratory: there is mild on and off cough, no shortness of breath, chest pain, hemoptysis, or chest tightness reported
  • Gastrointestinal: there is no reported vomiting, abdominal pain, change in bowel habits, diminished appetite, or bloody stool.
  • Genitourinary: there are no changes in urinary frequency, no burning sensation or pain during urination or coitus, no perineal itchiness or genital warts, and no perineal pain or ulcerations.
  • Neurological: there is no limb weakness or paralysis.
  • Musculoskeletal: There is no swelling, pain, change in color, or restricted range of motion in any of the joints.
  • Hematologic: there is no easy fatiguability or bleeding tendencies reported.
  • Lymphatics: There are no enlarged lymph nodes or spleen, and there is no unilateral leg swelling.
  • Endocrinologic: no changes in skin pigmentation, no heat intolerance, there is some level of unexplained lethargy, and there is emotional disturbances manifested as restlessness reported.

Objective:

Physical exam: vital signs: Temperature- 98.4, Pulse rate- 82, Respiratory rate 18, Blood Pressure 124/74mmHg  Height 5’0 Weight 118lbs.

Diagnostic results: Complete Blood Count, Thyroid function tests, Urea and Electrolytes, and Liver function tests are all within normal range

Assessment:

Mental Status Examination: F.B is a 27-year-old Caucasian female administrative assistant in car sales. She is of medium build and looks her stated age. She is well-kept and tidy. She is seated quietly although she is fidgety with minimal agitation.  She is oriented to time, place, and person with no abnormal movements or mannerisms. She appears concerned about her situation at her workplace and is preoccupied with the thought that her supervisor is in love with her. She appears guarded in manner. Emotionally, she appears tense. Her speech is of normal rate, volume, and coherence. Her mood is subjectively anxious. Her affect is mood congruent. Her stream of thought is coherent. She has persecutory delusions, referential delusions, somatic delusions, and erotomanic delusions. She is obsessed with the thoughts of being fired and of her supervisor being in love with her. She is generally anxious. She has no suicidal or homicidal ideations. There are no elicited perception disturbances like hallucinations or illusions. Her cognition, judgment, and insight are intact.

Primary Diagnosis: DSM-5 297.1 (F22) Delusional Disorder is the Primary diagnosis for F.B. She meets almost the whole of the diagnostic criteria for the diagnosis of the delusional disorder according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association, 2013). This patient exudes a myriad of subtypes of delusional disorder consisting of the erotomanic type, the persecutory type, and the somatic type, and she also shows delusions of reference. These are evidenced by the fact that she believes that her supervisor is in love with her despite strong evidence to the contrary since her supervisor has a girlfriend and has not shown any inappropriate actions towards her. She also believes that her boss and her supervisor have colluded to fire her. She also reports having neck pain, back pain, and a lump on her back which is not factual. She also believes that when her supervisor asks for her opinion at work he is using that to be lustful. This is a referential delusion. The duration of the illness is not as clear. She has not been able to make a sale for three weeks now, inferentially, she has been unwell for a minimum of three weeks. This lack of clarity in the duration throws a shadow on the main diagnosis as it requires a minimum of one month of symptomatology.

Differential Diagnoses: 295.40 (F20.81) Schizophreniform Disorder, 298.8 (F23) Brief Psychotic Disorder (BPD), and 295.70 (F25.1) Schizoaffective Disorder Depressive type all qualify as possible differential diagnoses. Brief Psychotic disorder is a highly probable diagnosis as its diagnosis only requires one of the delusions, catatonia, hallucinations, and disoriented speech (Sadock & Sadock, 2021). This patient has delusions. BPD also meets the timeline factor of less than a month. There is not a single stressor that can be mapped out to qualify for BPD. The diagnostic distinction between delusional disorder and schizophreniform and schizophrenia illness lies in the duration of illness and symptomatology. Both schizophrenia and schizophreniform illness are heralded with hallucinations which are rare in Delusional disorder (González-Rodríguez & Seeman, 2022). This makes both schizophrenia and schizophreniform disorders unlikely. Schizoaffective disorder can be qualified with the presence of delusions for the duration of the patient’s illness (Miller & Black, 2019). However, there are no symptoms of a major mood disorder that are shown by the patient.

Reflections: F.B presents with delusions which are classic symptoms of a psychotic disorder. However, having discussed the main diagnosis and the differential diagnoses, I realize there is a thin line that separates Delusional Disorder (DD) and Brief Psychotic Disorder (BPD). This lies in the duration of illness which from the case, is not clear. If I were to redo this case, I would inquire how and when the symptoms began. There is a lot of missing information on the family history of mental illness, personal history, and treatment history that I think would be crucial in the management of this case (Sarin et al., 2018). Proper patient management requires full disclosure of the health condition and history. Due to the limited disclosure, in this case, quality and effective care is almost an impossible phenomenon (Zolkefli, 2018). The most intriguing issue of ethical concern, in this case, is the operational challenges in the diagnosis and treatment; specifically in this case is inadequate information to make an extensively informed decision.

 

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th edition).

González-Rodríguez, A., & Seeman, M. V. (2022). Differences between delusional disorder and schizophrenia: A mini-narrative review. World Journal of Psychiatry, 12(5), 683–692. https://doi.org/10.5498/wjp.v12.i5.683

Miller, J. N., & Black, D. W. (2019). Schizoaffective disorder: A review. Annals of Clinical Psychiatry: Official Journal of the American Academy of Clinical Psychiatrists, 31(1), 47–53. https://pubmed.ncbi.nlm.nih.gov/30699217/

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry: behavioral sciences/clinical psychiatry (11th ed.). Wolters Kluwer.

Sarin, A., Jain, S., & Murthy, P. (2018). Turning the pages, or why history is important to psychiatry. Indian Journal of Psychiatry, 60(Suppl 2), S174–S176. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_429_17

Zolkefli, Y. (2018). The Ethics of Truth-Telling in Health-Care Settings. Malaysian Journal of Medical Sciences, 25(3), 135–139. https://doi.org/10.21315/mjms2018.25.3.14