Discussion: Decision Making When Treating Psychological Disorders NURS 6521

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Discussion: Decision Making When Treating Psychological Disorders NURS 6521

This week I chose ADHD Attention-Deficit/Hyperactivity Disorder; both my children suffer from this disease, and I do not fully understand it. I do not feel they have ever gotten adequate treatment for it, and I have seen them struggle throughout childhood into adolescence with all aspects of life due to this partially understood disease.

ADHD affects 5% to 11% of school-aged children being the most common neuropsychiatric disorder of childhood (Rosenthal & Burchum, 2021, p. 251). This disorder affects boys more than girls by two-thirds (Rosenthal & Burchum, 2021). This disease is not well understood but is thought to have a genetic component related to a mutation of the dopamine D4 receptor gene (DRD4) or a variation of the catechol-O-methyltransferase gene (COMT) (Block et al., 2021). Clinical manifestations include inattention, hyperactivity, and impulsivity (Rosenthal & Burchum, 2021). These individuals are frequently late, have forgetfulness in daily activities, distractibility, hyperactivity, and forgetfulness (Block et al., 2021). Not all these people will be hyperactive. Symptoms must be present before age twelve to be diagnosed (Block et al., 2021). These children cannot separate important stimuli from unimportant stimuli, which leads to difficulty staying on task and maintaining focus (Block et al., 2021). This disease may be related to brain development, including abnormalities in the “dopaminergic and noradrenergic neurotransmission system” (Block et al., 2021). Several other factors have been suggested to be a possible association with this disease that I will not be listed for this discussion.

The pharmacotherapeutics I chose for this patient’s pathophysiology started with Ritalin (methylphenidate) chewable tablet 10 mg orally in the morning. Eight-year-old female with a new diagnosis of ADHD and had not been on any medications in the past. On her first follow-up appointment four weeks after starting medication, her parents reported improvement in symptoms in the morning; however, the medication seems to be wearing off by the afternoon. Parents were concerned that the patient had reported her “heart felt funny” and noted a heart rate of 130 bpm in the clinic. During this visit, the medication was changed to Ritalin LA 20mg orally daily in the morning. This change will offer medication to be spread out over the day with a peak onset of four to seven hours and a duration of up to twelve hours (Davis’s Drug Guide, 2018). After the patient returns for a follow-up visit in four weeks, the parents state improvement in the patients’ schoolwork and states medication is lasting throughout the day. The patient report that the heart feeling has gone away. This dose would be maintained for an additional four weeks with a medication check-up in the clinic.

Ritalin is the drug of choice for ADHD for the start of care and has proven efficacy (Rosenthal & Burchum, 2021). No studies suggest one drug over another, and therefore if the first drug seems ineffective, the clinician should start considering second-line medications (Rosenthal & Burchum, 2021). Stimulants have possible adverse effects such as insomnia and growth suppression (Rosenthal & Burchum, 2021). Extended-release medications should be given as close to when the child wakes up to prevent insomnia as it will last up to twelve hours. If the child is experiencing decreased appetite, give medication after or during meals (Rosenthal & Burchum, 2021). Some providers recommend taking “drug holidays” where the child would not take medication on weekends; this is not recommended for all children (Rosenthal & Burchum, 2021).

References

Block, R., Macdonald, N. P., & Piotrowski, N. A. (2021). Attention deficit hyperactivity disorder (ADHD). Magill’s Medical Guide (Online Edition).

Davis’s Drug Guide. (2018). Davis’s drug guide for nurses (16th ed. ed.). F.A. Davis Company. Retrieved from Www.drugguide.com.: https://www.drugguide.com/ddo/mobile

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants (2nd Edition ed.). St. Louis, MO: Elsevier. Retrieved from vbk://9780323554954

Psychological disorders, such as depression, bipolar, and anxiety disorders can present several complications for patients of all ages. These disorders affect patients physically and emotionally, potentially impacting judgment, school and/or job performance, and relationships with family and friends. Since these disorders have many drastic effects on patients’ lives, it is important for advanced practice nurses to effectively manage patient care. With patient factors and medical history in mind, it is the advanced practice nurse’s responsibility to ensure the safe and effective diagnosis, treatment, and education of patients with psychological disorders.

Week 8 discussion

Initial Post

Depression is a serious mental health disorder that affects many citizens of the world. It is one of the most common mental health diagnoses we encounter in our practices. This disorder is caused by biological, psychological, social, or environmental factors. According to the American Psychiatric Association (APA) “Depression is a common and serious medical illness that negatively affects how you feel, the way you think and how you act”. In this somber assessment of the disease by the APA, we get a glimpse of the effects of the disease on the individual and the environment. Depression induces feelings of sadness, loss of interest in activities and friendships that we enjoyed in the past. It can lead to a variety of emotional and physical problems and can decrease your ability to function at full capacity at work and home.

“The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, 2013) of the American Psychiatric Association describes a series of conditions or mood disorders that include clinical depression, known as major depressive disorder”. (Oyama et al, 2020).

Major depressive disorder is characterized by a syndrome of symptoms, present during a two-week period and representing a clinically significant change from previous functioning. Some of the symptoms of this syndrome can be mild or severe. The following are some of the symptoms of depression:

  • Feeling sad or having a depressed mood
  • Loss of interest or pleasure in activities once enjoyed
  • Changes in appetite — weight loss or gain unrelated to dieting
  • Insomnia (trouble sleeping) or hypersomnia (sleeping too much)
  • Loss of energy or increased fatigue
  • Increase in purposeless physical activity (e.g., pacing, handwringing)
  • Feeling worthless or guilty
  • concentrating or making decisions
  • Thoughts of death or suicide

It is important to note that some of these symptoms must be severe or persistent to get noticed by loved ones or sometimes the individuals themselves. These symptoms according to the APA must last at least two weeks and represent a change in the patient’s previous level of functioning to warrant a diagnosis of major depressive disorder (MDD). These symptoms help practitioners in diagnosing MDD in patients. In addition to these symptoms, neuroimaging such as MRI, CT scan are also useful in the diagnosis and treatment of MDD.

The determinants of depression are genetic as well as psychosocial. According to Oyama et al, MDD is usually diagnosed in a patient twenties but major depressive episodes can occur at any age. The genetic determinants are familial links with higher rates of clinical depression in first-degree relatives and neurochemical imbalances in the brain of patients. Among the psychosocial determinants include stressors such as the death of a loved one, financial stress, loss of a job and unemployment, interpersonal problems, or traumatic world events such as natural disasters and war. This does not mean that all people who experience such events end up with a diagnosis of MDD but it is unclear why others and most don’t.

In this week’s decision making when treating psychological disorders, I selected the MDD case. This case is about a 70-year-old Hispanic American male who came to the United States when he was in high school with his father. His mother died back in Mexico when he was in school. This patient was being seen on an initial appointment for complaints of depression. The client was referred by his PCP after “routine” medical work-up to rule out an organic basis for his depression. This patient has no other health issues apart from some occasional back pain and “stiff” shoulders which he attributes to his current work as a laborer in a warehouse.

After the administration of the Montgomery- Asberg Depression Rating Scale (MARDS), the score of 51 indicated symptoms of severe depression. The max score on the scale is 60 so 51 is very high.  Since the patient has no previous history of treatment for depression or any other psychiatric condition, my assumption is that he is psychotropic naïve, so I chose to start patient on sertraline (Zoloft) 25mg by mouth daily in my decision point one.

The client returned in in four weeks endorsing improved symptoms but onset of erectile dysfunction (ED). It was encouraging to see that the medication therapy had some effect on the patient’s symptoms, but the effect of ED was unpleasant for him. In SSRIs, some of these effects could be dose related so I opted to increase dose to 50mg which is usually what is recommended as the initial dosing for MDD treatment. It is expected that 7-19% of patient would experience ED which may dissipate with time. If the patient continues to experience that side effects, then the medication may need changing.

The patient returned in 4 weeks to report further decrease in symptoms, but the side effect of ED was still happening, so I opted in my 3rd decision point to change medication to Bupropion (Wellbutrin) which is also used to treat depression but has no reported side effect of ED.  That decision was flagged as appropriate in the summary provided at the end of that phase of the exercise in this summary.

” Encouraging client to restart at previous dose would not be appropriate. Obviously, the side effect did not abate- so there is no reason to assume that it would abate at the previous dose. Re-starting the drug at 50% of starting dose may be appropriate to determine whether or not side effect is dose dependent. If the side effect of erectile dysfunction returns once the drug is returned to full dose, you would need to change the drug. Changing to Wellbutrin XL may be appropriate at this point but may worsen his insomnia. Additionally, guidelines tell us that another SSRI should be attempted for an adequate trial before switching drug classes.”

In a new set of decisions where I chose to go with venlafaxine (Effexor) 37.5mg as initial dose which provided no symptom relief when the patient returned in four weeks but showed signs of effectiveness at 75mg for another for weeks. Patient’s symptoms had decreased by 25% based on MARDS. The result of the MARDS was 38 after the increase but it is still relatively high so in the next decision point, I opted to increase the dose to 112.5mg by mouth daily. The decision point guidance was to alert patient of possible side effect as the dose is increased and educated patient to notify practitioner of any adverse events relating to the medication.

In the last decision point tress for this case, the patient was started on phenelzine (Nardil) 15mg by mouth TID. This landed the patient in the emergency department due to the side effect of postural hypotension. In the next decision point, I opted to stop phenelzine and begin Escitalopram (Lexapro) 20mg daily. Patient returned with news of improvement in symptoms about 25% but still high. The next decision is to maintain the patient on same dose and assess in the nest follow up or increase the dse to 25mg. The guidance to student in this exercise was to make sure that there is a wash out period for the phenelzine which is MAOI before the initiation of and SSRI like Lexapro.

Overall, I liked this exercise as a teaching tool. It helped to look at the various ways our decisions or treatment affect the patient and how we should go about deciding which treatment to start and how to continues or discontinue the treatment with full consideration of the patient’s presentation.

References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth edition. 2013.

Montgomery, S. A., & Asberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382-389.

National Institute of Mental Health. (Data from 2013 National Survey on Drug Use and Health.) www.nimh.nih.gov/health/statistics/prevalence/major-depression-among-adults.shtml

Oyama, O., PhD, & Piotrowski, N. A., PhD. (2020). Depression. Magill’s Medical Guide (Online Edition).

Photo Credit: Getty Images/iStockphoto

For this Discussion, you will select an interactive media piece to practice decision making when treating patients with psychological disorders. You will recommend the most effective pharmacotherapeutic to treat the psychological disorder presented and examine potential impacts of pharmacotherapeutics on a patient’s pathophysiology.

To Prepare
Review this week’s interactive media pieces and select one to focus on for this Discussion.
Reflect on the decision steps in the interactive media pieces, and consider the potential impacts from the administration of the associated pharmacotherapeutics on the patient’s pathophysiology.
By Day 3 of Week 8
Post a brief explanation of the psychological disorder presented and the decision steps you applied in completing the interactive media piece for the psychological disorder you selected. Then, explain how the administration of the associated pharmacotherapeutics you recommended may impact the patient’s pathophysiology. How might these potential impacts inform how you would suggest treatment plans for this patient? Be specific and provide examples.

By Day 6 of Week 8
Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days who selected a different interactive media piece on a psychological disorder, and provide recommendations for alternative drug treatments to address the patient’s pathophysiology.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

Submission and Grading Information
Grading Criteria

To access your rubric:

Week 8 Discussion Rubric

Post by Day 3 of Week 8 and Respond by Day 6 of Week 8

To Participate in this Discussion:

Week 8 Discussion

Week 8: Pharmacology for Psychological Disorders

How does an advanced practice nurse determine the best treatment option or pharmacotherapeutic to recommend for patients with psychological disorders?

Much like assessing or recommending pharmacotherapeutics for other conditions or disorders, as an advanced practice nurse, you may encounter a patient who presents with a psychological disorder. Understanding the guiding principles related to treating patients with psychological disorders as well as the effects of pharmacotherapeutics on a patient’s overall health and well-being is critical for the safe and effective delivery of care.

This week, you examine types of drugs prescribed to patients with psychological disorders. You also examine potential impacts of pharmacotherapeutics used to treat psychological disorders on a patient’s pathophysiology.

Learning Objectives
Students will:

Evaluate patients for treatment of psychological disorders
Analyze decisions made throughout the diagnosis and treatment of patients with psychological disorders
Analyze impacts of pharmacotherapeutics for psychological disorders on patient pathophysiology
Evaluate patients for treatment of neurological and musculoskeletal disorders
Analyze decisions made throughout the diagnosis and treatment of patients with neurological and musculoskeletal disorders
Justify decisions made throughout the diagnosis and treatment of patients with neurological and musculoskeletal disorders
Learning Resources
Required Readings (click to expand/reduce)

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.

Chapter 26, “Antipsychotic Agents and Their Use in Schizophrenia” (pp. 203–213)
Chapter 27, “Antidepressants” (pp. 214–226)
Chapter 28, “Drugs for Bipolar Disorder” (pp. 228–233)
Chapter 29, “Sedative-Hypnotic Drugs” (pp. 234–242)
Chapter 30, “Management of Anxiety Disorders” (pp. 243–247)
Chapter 31, “Central Nervous System Stimulants and Attention-Deficit/Hyperactivity Disorder” (pp. 248–254)
Required Media (click to expand/reduce)

Laureate Education (Producer). (2019a). Adult geriatric depression [Interactive media file]. Baltimore, MD: Author.

 

In this interactive media piece, you will engage in a set of decisions for prescribing and recommending pharmacotherapeutics to treat adult geriatric depression.

Laureate Education (Producer). (2019c). Attention deficit hyperactivity disorder [Interactive media file]. Baltimore, MD: Author.

In this interactive media piece, you will engage in a set of decisions for prescribing and recommending pharmacotherapeutics to treat attention deficit hyperactivity disorder.

Laureate Education (Producer). (2019d). Bipolar therapy [Interactive media file]. Baltimore, MD: Author.

In this interactive media piece, you will engage in a set of decisions for prescribing and recommending pharmacotherapeutics for bipolar therapy.

Laureate Education (Producer). (2019g). Generalized anxiety disorder [Interactive media file]. Baltimore, MD: Author.

In this interactive media piece, you will engage in a set of decisions for prescribing and recommending pharmacotherapeutics to treat generalized anxiety disorder.

Speed Pharmacology. (2016). Pharmacology – Antidepressants – SSRIs, SNRIs, TCAs, MAOIs, Lithium (Made Easy) [Video]. https://www.youtube.com/watch?v=T25jvLC6X0w&t=3s

Note: This media program is approximately 19 minutes.

Speed Pharmacology. (2018). Pharmacology – Benzodiazepines, Barbiturates, Hypnotics (Made Easy) [Video]. https://www.youtube.com/watch?v=4ZHudeMho8g&t=24s

Note: This media program is approximately 8 minutes.

Rubric Detail

Select Grid View or List View to change the rubric’s layout.

Name: NURS_6521_Week8_Discussion_Rubric
Grid View
List View
Excellent Good Fair Poor
Main Posting
45 (45%) – 50 (50%)
Answers all parts of the discussion question(s) expectations with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources.

Supported by at least three current, credible sources.

Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.
40 (40%) – 44 (44%)
Responds to the discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module.

At least 75% of post has exceptional depth and breadth.

Supported by at least three credible sources.

Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.
35 (35%) – 39 (39%)
Responds to some of the discussion question(s).

One or two criteria are not addressed or are superficially addressed.

Is somewhat lacking reflection and critical analysis and synthesis.

Somewhat represents knowledge gained from the course readings for the module.

Post is cited with two credible sources.

Written somewhat concisely; may contain more than two spelling or grammatical errors.

Contains some APA formatting errors.
0 (0%) – 34 (34%)
Does not respond to the discussion question(s) adequately.

Lacks depth or superficially addresses criteria.

Lacks reflection and critical analysis and synthesis.

Does not represent knowledge gained from the course readings for the module.

Contains only one or no credible sources.

Not written clearly or concisely.

Contains more than two spelling or grammatical errors.

Does not adhere to current APA manual writing rules and style.
Main Post: Timeliness
10 (10%) – 10 (10%)
Posts main post by day 3
0 (0%) – 0 (0%)
0 (0%) – 0 (0%)
0 (0%) – 0 (0%)
Does not post by day 3
First Response
17 (17%) – 18 (18%)
Response exhibits synthesis, critical thinking, and application to practice settings.

Responds fully to questions posed by faculty.

Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.

Demonstrates synthesis and understanding of learning objectives.

Communication is professional and respectful to colleagues. .

Responses to faculty questions are fully answered, if posed.

Response is effectively written in standard, edited English.
15 (15%) – 16 (16%)
Response exhibits synthesis, critical thinking, and application to practice settings.

Responds fully to questions posed by faculty.

Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.

Demonstrates synthesis and understanding of learning objectives.

Communication is professional and respectful to colleagues. .

Responses to faculty questions are fully answered, if posed.

Response is effectively written in standard, edited English.
13 (13%) – 14 (14%)
Response is on topic and may have some depth.

Responses posted in the discussion may lack effective professional communication.

Responses to faculty questions are somewhat answered, if posed.

Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.
0 (0%) – 12 (12%)
Response may not be on topic and lacks depth.

Responses posted in the discussion lack effective professional communication.

Responses to faculty questions are missing.

No credible sources are cited.
Second Response
16 (16%) – 17 (17%)
Response exhibits synthesis, critical thinking, and application to practice settings.

Responds fully to questions posed by faculty.

Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.

Demonstrates synthesis and understanding of learning objectives.

Communication is professional and respectful to colleagues. .

Responses to faculty questions are fully answered, if posed.

Response is effectively written in standard, edited English.
14 (14%) – 15 (15%)
Response exhibits critical thinking and application to practice settings.

Communication is professional and respectful to colleagues.

Responses to faculty questions are answered, if posed.

Provides clear, concise opinions and ideas that are supported by two or more credible sources.

Response is effectively written in standard, edited English.
12 (12%) – 13 (13%)
Response is on topic and may have some depth.

Responses posted in the discussion may lack effective professional communication.

Responses to faculty questions are somewhat answered, if posed. .

Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.
0 (0%) – 11 (11%)
Response may not be on topic and lacks depth.

Responses posted in the discussion lack effective professional communication.

Responses to faculty questions are missing.

No credible sources are cited.
Participation
5 (5%) – 5 (5%)
Meets requirements for participation by posting on three different days.
0 (0%) – 0 (0%)
0 (0%) – 0 (0%)
0 (0%) – 0 (0%)
Does not meet requirements for participation by posting on 3 different days
Total Points: 100
Name: NURS_6521_Week8_Discussion_Rubric

NURS_6521_Week8_Discussion_Rubric

Excellent Good Fair Poor
Main Posting
Points Range: 45 (45%) – 50 (50%)

Answers all parts of the discussion question(s) expectations with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources.

Supported by at least three current, credible sources.

Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.

Points Range: 40 (40%) – 44 (44%)

Responds to the discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module.

At least 75% of post has exceptional depth and breadth.

Supported by at least three credible sources.

Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.

Points Range: 35 (35%) – 39 (39%)

Responds to some of the discussion question(s).

One or two criteria are not addressed or are superficially addressed.

Is somewhat lacking reflection and critical analysis and synthesis.

Somewhat represents knowledge gained from the course readings for the module.

Post is cited with two credible sources.

Written somewhat concisely; may contain more than two spelling or grammatical errors.

Contains some APA formatting errors.

Points Range: 0 (0%) – 34 (34%)

Does not respond to the discussion question(s) adequately.

Lacks depth or superficially addresses criteria.

Lacks reflection and critical analysis and synthesis.

Does not represent knowledge gained from the course readings for the module.

Contains only one or no credible sources.

Not written clearly or concisely.

Contains more than two spelling or grammatical errors.

Does not adhere to current APA manual writing rules and style.

Main Post: Timeliness
Points Range: 10 (10%) – 10 (10%)
Posts main post by day 3
Points Range: 0 (0%) – 0 (0%)
Points Range: 0 (0%) – 0 (0%)
Points Range: 0 (0%) – 0 (0%)
Does not post by day 3
First Response
Points Range: 17 (17%) – 18 (18%)

Response exhibits synthesis, critical thinking, and application to practice settings.

Responds fully to questions posed by faculty.

Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.

Demonstrates synthesis and understanding of learning objectives.

Communication is professional and respectful to colleagues. .

Responses to faculty questions are fully answered, if posed.

Response is effectively written in standard, edited English.

Points Range: 15 (15%) – 16 (16%)

Response exhibits synthesis, critical thinking, and application to practice settings.

Responds fully to questions posed by faculty.

Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.

Demonstrates synthesis and understanding of learning objectives.

Communication is professional and respectful to colleagues. .

Responses to faculty questions are fully answered, if posed.

Response is effectively written in standard, edited English.

Points Range: 13 (13%) – 14 (14%)

Response is on topic and may have some depth.

Responses posted in the discussion may lack effective professional communication.

Responses to faculty questions are somewhat answered, if posed.

Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.

Points Range: 0 (0%) – 12 (12%)

Response may not be on topic and lacks depth.

Responses posted in the discussion lack effective professional communication.

Responses to faculty questions are missing.

No credible sources are cited.

Second Response
Points Range: 16 (16%) – 17 (17%)

Response exhibits synthesis, critical thinking, and application to practice settings.

Responds fully to questions posed by faculty.

Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.

Demonstrates synthesis and understanding of learning objectives.

Communication is professional and respectful to colleagues. .

Responses to faculty questions are fully answered, if posed.

Response is effectively written in standard, edited English.

Points Range: 14 (14%) – 15 (15%)

Response exhibits critical thinking and application to practice settings.

Communication is professional and respectful to colleagues.

Responses to faculty questions are answered, if posed.

Provides clear, concise opinions and ideas that are supported by two or more credible sources.

Response is effectively written in standard, edited English.

Points Range: 12 (12%) – 13 (13%)

Response is on topic and may have some depth.

Responses posted in the discussion may lack effective professional communication.

Responses to faculty questions are somewhat answered, if posed. .

Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.

Points Range: 0 (0%) – 11 (11%)

Response may not be on topic and lacks depth.

Responses posted in the discussion lack effective professional communication.

Responses to faculty questions are missing.

No credible sources are cited.

Participation
Points Range: 5 (5%) – 5 (5%)
Meets requirements for participation by posting on three different days.
Points Range: 0 (0%) – 0 (0%)
Points Range: 0 (0%) – 0 (0%)
Points Range: 0 (0%) – 0 (0%)
Does not meet requirements for participation by posting on 3 different days
Total Points: 100
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