NURS 5002 Case Study #3

Refer to Case Study Grading Guidelines and Grading Rubric for a complete description of requirements and
grading criteria. To make the case study as real as possible, while you are working through the case study
do not look ahead at the information provided.

You are working in a primary care office and the next scheduled patient is a 45 yo female (Mrs. Vickers)
who is having female problems.

The chart reveals the following:

PMH SH MEDS
Hypothyroidism Lives at home with spouse and 18 Synthroid 125 mcg/d
Cholecystectomy y.o. son Zyrtec 10 mg QD
C-Section Works full time
Appendectomy Socially drinks occasionally Prilosec OTC PRN
Sinus Infections Smoker -1 ppd
Depression (successfully treated 4 Allergies
years ago) NKDA

PREVENTION
Mammogram normal 9 mos. ago
Pap smear normal 9 mos. ago
Flu shot last year

After reviewing the chart, what are potential concerns? The patient has a history of depression. Although she
was successfully treated four years ago, in my own clinical experience symptoms of depression and anxiety have a
tendency to return, and female problems seem to heighten emotion. Smoking one half to one pack per day, is
often used to relieve feelings of anxiety. Her eighteen year old son (teenager) lives in the home. Is he a well-
disciplined teenager, or is he a rebellious teenager that is experimenting with the wrong crowd, regardless the
worry of raising a teenager can also lead to anxiety and depression. Working full time can also leave little time for a
mother to spend quality time with their children and take time away from many household duties, which can leave
many women with feelings of anxiety, depression, and guilt. Does she have a good support system at home among
her family? Hypothyroidism has a tendency to often cause symptoms of tiredness and fatigue. She takes Zyrtec, so
she more than likely has seasonal or environmental allergies. How does this affect her? A lot of people suffering
from allergies have symptoms of tiredness and feeling drained of energy.

You interview Mrs. Vickers and she states that she is worried that she is going through the change. You
further question her and find out the following:

Mrs. Vickers continues to have a menstrual period every 45 -60 days that last 1-3 days with minimal flow
and has been like this for about the past 8-9 months. She is very restless at night and is having difficulty
sleeping. She has been under some additional stress at work and her son is a senior is high school and
they have been very busy looking at colleges, which also added to her stress. She doesnt think she is
having hot flashes but when she wakes up at night she is hot but just thinks that is from being so restless
but states I guess they could be hot flashes, I dont know since I have never had them before. Denies
any family history of cardiac disease, breast cancer or other cancers; Denies personal history of cancer,
DVT, migraines, cardiac problems, decreased libido but does state there has been a decreased frequency
because I have just been so busy.

ROS
- vaginal itching, burning or abnormal DC; urinary frequency or urgency; palpitations, chest pain, SOB, perfuse
sweating
+ frequent headaches, irritability, insomnia, fatigue, stress

Physical Exam
EENT: PERR; TMs intact; nasal passages pink moist, no lesions; no pharyngeal edema, mucus membranes pink and
moist; no carotid bruits; no cervical lymphadenopathy; thyroid without palpable masses or enlargement
Heart: S1 S2 RRR without murmurs, clicks or rubs
Lungs: CTA bilaterally, no wheezes, crackles or rubs
ABD: soft, non-tender; +BS X4 quads; no masses, organomegaly or bruits; ovaries are not palpable;
Genitalia: deferred due to normal exam and pap 9 months ago

VS
BP 120/72 HR 78
What other question(s) would you like to ask Mrs. Vickers to assist with your diagnosis? What
other information would you like to have had? Insomnia: What is your typical sleep patterns? (Do you go to bed
and wake typically at the same time each day? Typical diet and typical time you eat dinner (is she eating a large meal late in the
evening)? Do you smoke or consume caffeine or alcohol late in the evening?) Secondary insomnia may be associated with aging
(Huether, Rodway, & DeFriez, 2015, p. 504). Depression/ Anxiety: Has she felt any similar symptoms to depression as she
experienced with her depression diagnosis in the past? Does she have feelings of anxiety? Has anyone in the immediate family ever
experienced depression or anxiety? Genetics play a major role in the development of both depression and anxiety (Takahashi, 2015).
Perimenopause: What were her periods normally like before the onset of current symptoms? (How often, length of periods, how
many days between cycles?); What was the ages of her mother and immediate female relatives when they started going through the
change? It [menopause] is genetically predetermined and has been documented by family history (Tufts, Rodway, Huether, &
Deneris, 2015, p. 791).; The patients weight and frame? Thinner women tend to experience menopause at a slightly younger age
(Tufts et al., 2015, p. 791). Estradiol, projesterone, and LH levels? During perimenopause, estradiol levels are marked increased,
progesterone levels decrease, and LH levels increase (Tufts et al.,, 2015, p. 793).

DIFFERENTIATION OF DISEASE (may add other columns if needed)

DISEASE #1 DISEASE #2 DISEASE #3

Insomnia
Pathophysiology Sleep disorder characterized by
difficulty falling or staying
asleep. Primary insomnia is
when a person has insomnia that
is not associated with any health
problem or any other reason.
Secondary insomnia is when a
person has insomnia because of
some other reason or problem.
Factors related to secondary
insomnia include: stress, illness,
physical or emotional pain,
environmental factors,
medications, or substance use
Depression/Anxiety
Depression: Variant in the
serotonin transporter (5-HT-
T) that exists as either a short
or long allele. The
serotonin transporter serves
in the reuptake of serotonin
at the synapse and may
moderate the serotonergic
response to stress
(Takahashi, 2015, p. 648).
Anxiety: (Generalized
anxiety disorder [GAD])
Abnormalities in the
norepinephrine and serotonin
Perimenopause
According to Tufts et al.
(2015), perimenopause is
the transitional period
between reproductive and
nonreproductive years
(pp. 791 and 793).
Changes in hormones
occur including increased
estradiol levels, decreased
progesterone levels, and
disturbed ovarian-
pituitary-hypothalamic
feedback relationship
causing increased
 such as caffeine or alcohol
(Chanin, 2014).
Signs/Symptoms Sleepiness during the day, general Depression: Unremitting
tiredness, irritability, and
problems with concentration and despair, insomnia, loss of
memory (Chanin, 2014).
systems (Takahashi, 2015, p. luteinizing hormone levels
655). (Tufts et al., 2015, p. 793).
(Panic disorder) Some
studies suggest the
cholecystokinin receptor
gene on chromosome 11p
may be linked to panic
disorder. It is believed that
heightened pH sensitivity in
the amygdala generates
fearful perceptions activating
the cerebral cortex and
neuronal circuits in the
temporal lobe and brainstem.
May also involve the GABA-
benzodiazepine receptor
system (Takahashi, 2015, p.
654).
Lengthening of menstrual
feelings of sadness and cycle, correlating with
anovulatory cycles.
appetite and body weight, Unpredictable or irregular
reduced interest in ovulation (Tufts et al.,
pleasurable activities and 2015). Other symptoms
interpersonal relationships, include: hot flashes, breast
sleep disturbances, reduced tenderness, worsening
motor activity and fatigue, premenstrual syndrome,
feelings of worthlessness and low sex drive, fatigue,
guilt, perceive pessimistic or irregular periods, vaginal
negative outcomes, dryness or discomfort
diminished ability to function during sexual intercourse,
and concentrate (Takahashi, urinary urgency or stress
2015, pp. 650-651). incontinence, mood

Treatments: Treatment of any underlying
conditions that may be causing
insomnia. Behavioral approaches
including: trying to go to sleep at
the same time each night and
getting up at the same time each
morning, avoid naps during the
day, make your bedroom
comfortable (dark, quiet, not too
hot or too cold) and avoid using
your bedroom for anything other
than sleep, avoid caffeine,
nicotine, alcohol, and large meals
late in the day, a light snack late
in the evening may help you
sleep, get regular exercise but do
not exercise right before bedtime,
Anxiety: (GAD) swings, and trouble
Restlessness, muscle tension, sleeping (Johnson, 2014).
irritability, easily fatigued,
difficulty concentrating, and
difficulty sleeping
(Takahashi, 2015, p. 655)
(Panic disorder)
Lightheadedness,
tachycardia, difficulty
breathing, chest discomfort,
generalized sweating,
generalized weakness,
trembling, abdominal
distress, chills or hot flashes,
worry, and agoraphobia
(Takahashi, 2015, p. 654)
Depression: Antidepressant Hot flashes can be treated
drugs such as MAOIs, TCAs, by low does birth control
SSRIs, and SNRIs and/ or pills or patch for a short
psychotherapy. time, as well as vaginal
Electroconvulsive therapy ring, and progesterone
(ECT) can be used when injections. Also to prevent
individuals fail to respond to pregnancy during
antidepressants or in severe perimenopause, birth
depression, pregnancy, control pills may be
suicidal, or psychotic prescribed. Take measures
episodes (Takahashi, 2015, p. to enhance general
651). wellbeing such as exercise,
Anxiety: (GAD) 5- stop smoking, drink less
HT/norepinephrine reuptake alcohol, maintain a healthy
inhibitors (such as weight, ensure enough
venlafaxine) or SSRIs calcium in diet or calcium
(paroxetine or escitalopram), supplements, multivitamin

Complications:
What is your choice for the given
try relaxation techniques before
bed (reading, listen to music,
taking a bath), make a to do list
or journal entry to try and get
thoughts off of your mind before
bed.
If all other techniques and
interventions fail, a rapid, short-
acting sleeping pill may be
prescribed for a limited time.
Avoid over the counter sleep aids
as they may have undesired side
effects and loose effectiveness
over time (Chanin, 2014).
Persons suffering with insomnia
reports a decrease in quality of
life. Physical and mental
problems can result in lack of
sleep. Some complications
include: lower performance at
work or school, slowed reaction
time, depression or anxiety,
weight gain, irritability, increased
risk of obtaining or complications
associated with long term
medical conditions, and
substance abuse (Mayo Clinic,
2014).
buspirone, along with
behavior therapy for
relaxation (Takahashi, 2015,
p. 655).
(Panic disorder) Cognitive
behavior therapy (CBT)
and/or antidepressant
medications (SSRIs and
SNRIs), and
benzodiazepines. Relaxation
techniques (breathing
exercises to control
hyperventilation) Takahashi,
2015, pp. 654-655).
Depression: Suicidal risk
increases (Takahashi, 2015,
p. 651).
Anxiety: GAD tends to be
chronic and frequent
complication is substance
abuse, which may result from
self-medication with alcohol
or drugs to relieve anxiety
symptoms (Takahashi, 2015,
p. 655).
In panic disorders,
agoraphobia is a
complication which in severe
cases can cause a person to
become housebound
(Takahashi, 2015, p. 654).
supplement, get adequate
rest by trying to go to bed
and wake around the same
time each day. Speaking
with a counselor or
therapist or taking
antidepressants to in order
to treat mood swings
(Johnson, 2014).
Irregular periods are
common during
perimenopause, however
certain symptoms need
further investigation to
possibly rule out other
causes. Symptoms to be
concerned with include:
heavy periods or excessive
clotting during periods,
periods lasting several
days longer than usual,
spotting between periods
or after sexual intercourse,
or periods too close
together (Johnson, 2014).
scenario?

Why did you make this choice? Give good rational for your decision. Perimenopause- The patient is 46 years old, with complaints
of menstrual periods averaging every 45-60 days, lasting one- three days with minimal flow, for the past eight to nine months, and
possible hot flashes. Although, many of her symptoms such as fatigue, insomnia, stress, irritability, and headaches fall into both
categories of insomnia and depression/ anxiety, they also fall into the category of many symptoms associated with perimenopause.
According to Tufts et al. (2015), in North America, the average age of menopause is 50.5 to 51.4 years of age. On average,
menopause can occur up to two years sooner in persons who smoke and are underweight (not sure about patients weight, but we do
know that she smokes). Approximately five to ten years before menopause, around ninety percent of women begin to experience
changes in menstrual cycles and the perimenopause period can last from two to eight years (Tufts et al., 2015, pp. 791-793).

COMPARISON OF MEDICATION (may add other columns if needed)

MEDICATION #1 MEDICATION #2 MEDICATION #3 MEDICATION #4

Venlafaxine Eszopiclone FEMhrt 1/5 Brevicon
Class/Type of med Selective Serotonin Hypnotic Hormone replacement Oral contraceptive
and Norepinephrine therapy
Reuptake Inhibitors
(SNRIs)

Mechanism of Action
Increasing amounts of Slowing activity in the Replacing estrogen Combination of estrogen
serotonin and brain to allow sleep. hormone that is no longer and progestin work by
norepinephrine in the being made by the body. preventing ovulation,
brain to help maintain they also change the
mental balance. lining of the uterus to
prevent pregnancy from
developing and change
 the mucus at the cervix
to prevent sperm from
entering. To treat acne
by decreasing the
amounts of certain
natural substances that
cause acne.
Indications Depression; hot Insomnia. Treat certain symptoms Used to prevent
flashes in of menopause. Estrogen pregnancy; relieve
postmenopausal reduces hot flashes, symptoms of
women or hot flashes vaginal symptoms premenstrual dysphoric
with breast cancer (itching, burning, and disorder; and treat acne.
treatment. dryness), difficulty with
urination, prevents
osteoporosis in
menopausal women.
Progestin is added to
reduce risk of uterine
cancer in women who
still have a uterus.
Side Effects Drowsiness, weakness Headache, pain daytime Headache, upset Nausea/ vomiting,
or tiredness, dizziness, drowsiness, stomach/ vomiting, stomach cramps or
headache, nightmares, lightheadedness, stomach cramps or bloating, diarrhea,
nausea/ vomiting/ dizziness, loss of bloating, diarrhea, constipation, gingivitis,
stomach pain, coordination, nausea/ appetite and weight increased or decreased
constipation or vomiting, heartburn, changes, changes in sex appetite, weight gain or
diarrhea, gas, unpleasant taste, dry drive or ability, loss, brown or black
heartburn, burping, mouth, unusual dreams, nervousness, brown or skin patches, acne, hair
dry mouth, change in decreased sexual desire, black skin patches, acne, growth in unusual
ability to taste food, painful menstrual edema of hands/ feet/ or places, bleeding or
loss of appetite, periods, breast lower legs, bleeding or spotting between
weight loss, enlargement in males, spotting between menstrual periods,
uncontrollable shaking hives/ rash/ itching/ menstrual periods, changes in menstrual
of a part of the body, swelling of the eyes, changes in menstrual flow, painful or missed
pain/ burning/ face, lips, tongue, hands, flow, breast tenderness/ periods, breast
numbness/ tingling, feet, ankles, or lower enlargement/ or tenderness/ enlargement/
muscle tightness, legs/ difficulty breathing discharge, difficulty or discharge, swelling/
twitching, yawning, or swallowing/ feeling wearing contact lenses, redness/ irritation/
sweating, hot flashes/ that the throat is closing, double vision, severe burning/ or itching of
flushing, frequent and hoarseness. abdominal pain, the vagina, white
urination, difficulty yellowing of skin or vaginal discharge,
urinating, sore throat/ eyes, severe mental severe headache, severe
chills/ other signs of depression, unusual vomiting, speech
infection, ringing in bleeding, loss of appetite, problems, dizziness or
the ears, changes in rash, extreme tiredness/ fainting, weakness or
sexual desire or weakness/ or lack of numbness or arm or leg,
ability, enlarged energy, fever, dark- crushing chest pain or
pupils, rash/ hives/ colored urine, light- chest heaviness,
itching/ difficulty colored stool. coughing up blood,
breathing or shortness of breath, leg
swallowing, chest pain, partial or complete
pain, fast or pounding loss of vision, double
heartbeat, seizures, vision, bulging eyes,
unusual bleeding or severe stomach pain,
bruising, eye pain or yellowing of skin or
redness, fever/ eyes, loss of appetite,
sweating/ confusion/ extreme tiredness/
severe muscle weakness/ or lack of
stiffness, problems energy, fever, dark-
with coordination, colored urine, light-
hallucinations, and colored stool, edema of
coma. the hands/ feet/ or lower
legs, depression
(especially if you also
have trouble sleeping,
tiredness, loss of energy,
 or other mood changes),
unusual bleeding, rash,
and menstrual bleeding
that is unusually heavy
or lasting longer than 7
days.
Complications Children, teenagers, Only take at bedtime May increase risk of May increase risk of
and young adults and when you are able developing endometrial development of benign
taking antidepressants to stay in bed for at least cancer and gallbladder liver tumors that have
are at increased risk of 7-8 hours after taking. disease. the potential to rupture
suicidal thoughts or Should not eat or drink Smoking while taking and cause serious
tendencies. Should grapefruit juice while this medication may bleeding. May increase
not take venlafaxine taking this medication. increase risk of serious risk of development of
along with or within Use with caution when side effects such as: liver cancer or breast
14 days of stopping taking: antidepressants, blood clots, heart attack, cancer, heart attack,
treatment with antifungals, and stroke. Smoking stroke, or blood clots.
MAOIs. antihistamines, may also decrease the Having a history of
Should be used in clarithromycin, certain effectiveness of the blood clots,
caution along with HIV protease inhibitors, medication. thrombophilia, CAD,
some other medications used to Use with caution when cerebrovascular disease,
medications including: treat anxiety/ mental taking because of risk of CVA or TIAs, irregular
anticoagulants, illness/ or seizures, increased side effects: heartbeat, heat attack,
amiodarone, Tagamet, nefazodone, olanzapine, acetaminophen, chest pain, diabetes,
clozapine, diuretics, rifampin, sedatives, anticoagulants, headaches accompanied
duloxetine, Haldol, other sleeping pills or cyclosporine, by visual changes,
imipramine, indinavir, tranquilizers, or medications for seizures, weakness, and dizziness,
ketoconazole, Zyvox, troleandomycin. morphine, oral steroids, high blood pressure,
lithium, medications Should be used in rifampin, salicylic acid, breast, uterine, cervical,
to treat anxiety/ caution if you consume temazepam, theophylline, or vaginal cancers, liver
mental illness/ pain/ alcohol, or have ever thyroid medication. disease, cancer, or
seizures/ weight loss/ abused alcohol, street Do not take if you are tumors, yellowing of the
or migraines, drugs, or prescription pregnant or skin or eyes during
methadone, methylene pain medications. If breastfeeding, estrogen pregnancy, unexplained
blue, ritonavir, SSRIs, you have had suicidal and progestin may harm vaginal bleeding,
sibutramine, sleeping thoughts or tendencies. the fetus. adrenal insufficiency,
pills, and tranquilizers. If you have history of May need to take a kidney disease,
As well as herbal depression, mental calcium supplement overweight, breast
medications such as illness, lung disease or while taking this problems such as lumps
St. Johns wort and breathing problems, or medication to decrease or abnormal
tryptophan. liver disease. risk of developing mammogram, asthma,
This medication can Should not use if osteoporosis due to toxemia, migraine
make you drowsy, pregnant or menopause. headaches, depression,
alcohol or depressant breastfeeding. gallbladder disease, or
medications can make Use with caution when excessive weight gain or
this worse. driving a car or bloating during
May cause angle- operating machinery, menstrual cycle, or have
closure glaucoma. this medication can a family history of
Should be used in cause drowsiness in the breast cancer may
caution in patients daytime. Some people increase your risk.
with recent heart have been known to get Do not take if you are
attack, current high up from sleep and drive, pregnant or
blood pressure or high prepare food, have breastfeeding or plan to
cholesterol, seizures, sexual contact, make become pregnant.
heart, kidney, liver, or phone calls, and other Needs to be used in
thyroid disease. activities while partially caution when taking any
asleep and have no or of the following
little memory of the medications: St. Johns
events when waking. wort, acetaminophen,
Do not drink alcohol certain antibiotics
while taking this (ampicillin,
medication, it can clarithromycin,
intensify side effects. erythromycin, isoniazid,
Change in mental health metronidazole,
may occur. minocycline, rifabutin,
rifampin, tetracycline,
and troleandomycin),
 anticoagulants,
antifungals, atorvastatin,
clofibrate, cyclosporine,
bosentan, cimetidine,
danazol, delaviridine,
diltiazem, fluoxetine,
HIV protease inhibitors,
medications for
seizures, modafinil,
morphine, nefazodone,
and oral steroids.
References (MedlinePlus, 2016d) (MedlinePlus, 2016c) (MedlinePlus, 2016a) (MedlinePlus, 2016b)

What is your choice for

the given scenario?
(place X in box)

Why did you make this choice? Give good rational for your decision. At this time I would prescribe an antidepressant, such as
venlafaxine, in order to help with symptoms such as the possible hot flashes, insomnia, and stress (Johnson, 2014; MedlinePlus,
2016d). I would use venlafaxine with care due to current hypothyroidism (MedlinePlus, 2016d). Oral contraceptives are the treatment
of choice to treat hot flash symptoms and prevent pregnancy during perimenopause, but due to her current history of cigarette use, I
would be extremely hesitant to prescribe oral contraceptives at this time (Johnson, 2014). FEMhrt 1/5 and Brevicon both should be
used in extreme caution with persons who smoke cigarettes, due to the increased risk of complications such as heart attacks, blood
clots, and stroke (she is also experiencing increased stress in her life which also increases the risk of heart attack and stroke)
(MedlinePlus, 2016a; MedlinePlus 2016b). Brevicon should also be used in caution because of her history of depression
(MedlinePlus, 2016b). Also, FEMhrt 1/5 should be used in caution when taking levothyroxine because of increased side effects of the
medication, dosage may need to be adjusted (MedlinePlus, 2016a). I would be very cautious about prescribing eszopiclone due to her
history of depression (MedlinePlus, 2016c).

What type of patient teaching will you include with your visit? Venlafaxine could take up to two weeks for the patient to begin
experiencing relief of symptoms. She should not stop this medication without first consulting her health care provider. This
medication should not be taken with any over the counter mood stabilizers, such as St Johns wort, or be taken with alcohol due to an
increase in side effects of the medication. I would explain to her that although she is being prescribed an antidepressant,
this does not necessarily mean that she is being diagnosed with depression. Antidepressants, such as venlafaxine,
help with some of the symptoms she is experiencing such as the possible feelings of hot flashes, insomnia, and
stress which could all be related to perimenopause. She needs to be aware that although she may be experiencing
signs of perimenopause, she still has the potential to become pregnant, therefore precautions should be used when
having sexual intercourse. I would explain that other symptoms, such as hot flashes, and the potential risk of
pregnancy may also be treated with oral birth control pills, but explain the importance of smoking cessation before
and during the use of these pills due to the increased risk of dangerous side effects. Smoking while taking these
pills increases the risk of developing serious complications including heart attack, blood clots, including pulmonary
embolism, and stroke (MedlinePlus, 2016b). Stress can also increase risk of heart disease and stroke, as a result
stress management techniques should be discussed. Explain the importance of taking measures to enhance general wellbeing
such as exercise, stop smoking, drink less alcohol, maintain a healthy weight, ensure enough calcium in diet or calcium supplements,
multivitamin supplement, get adequate rest by trying to go to bed and wake around the same time each day may help with some of her
general symptoms.

References

Chanin, L. (2014, August 21). An overview of insomnia. In WebMD.com. Retrieved from: http://www.webmd.com/sleep-

disorders/guide/insomnia-symptoms-and-causes

Huether, S. E., Rodway, G., & DeFriez, C. (2015). Pain, temperature regulation, sleep, and sensory function. In McCance, K. L.,

Huether, S. E., Brashers, V. L. & Rote, N. S. (Eds.), Pathophysiology: The biologic basis for disease in adults and children (7th

ed.) (pp. 484-526). Saint Louis, MO: Elsevier Mosby.

Johnson, T. (2014, June 03). Perimenopause. In WebMD.com. Retrieved from: http://www.webmd.com/menopause/guide/guide-

perimenopause

Mayo Clinic [Internet]. (2014, April 04). Diabetes and conditions: Insomnia complications. Retrieved from:

http://www.mayoclinic.org/diseases-conditions/insomnia/basics/complications/CON-20024293
MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US) (2016a). Estrogen and progestin (hormone replacement

therapy); [revised 2015, September 15]. Retrieved from: https://www.nlm.nih.gov/medlineplus/druginfo/meds/a601041.html

MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US) (2016b). Estrogen and progestin (oral contraceptives);

[revised 2015, September 15]. Retrieved from: https://www.nlm.nih.gov/medlineplus/druginfo/meds/a601050.html

MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US) (2016c). Eszopiclone; [revised 2014, May 15].

Retrieved from: https://www.nlm.nih.gov/medlineplus/druginfo/meds/a605009.html

MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US) (2016d). Venlafaxine; [revised 2014, November 15].

Retrieved from: https://www.nlm.nih.gov/medlineplus/druginfo/meds/a694020.html

Takahashi, L. K. (2015). Neurobiology of schizophrenia, mood disorders, and anxiety disorders. In McCance, K. L., Huether, S. E.,

Brashers, V. L. & Rote, N. S. (Eds.), Pathophysiology: The biologic basis for disease in adults and children (7th ed.) (pp. 641-

659). Saint Louis, MO: Elsevier Mosby.

Tufts, G., Rodway, G., Huether, S. E., & Deneris, A. (2015). Structure and function of the reproductive system. In McCance, K. L.,

Huether, S. E., Brashers, V. L. & Rote, N. S. (Eds.), Pathophysiology: The biologic basis for disease in adults and children (7th

ed.) (pp. 768-799). Saint Louis, MO: Elsevier Mosby.