what people say to you, even when they are speaking to you directly?
43 minutes ago
Isata George
Week 9 Case 2
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“The scatter-brained mother whose daughter has ADHD like mother like daughter.”
Targeted Question for Client
Are you currently employed? And if employed do you have any difficulty following instructions on the job?
How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to before they can finish them themselves?
The above questions will serve as part of the screening tool. Asking the client these questions will give me an idea if they are aware of the behavioral symptoms of ADHD and assist me with their diagnosis, especially if the clinician only have limited time with each patient. Based on the results, the PMHNP will possibly send the patient for further psychological evaluation, or even prescribe appropriate medication.,
Additional People to interview regarding Patient behavior
To obtained detailed information regarding the patient presenting symptoms, it is critical to interview certain individuals who close to the patient. I will interview colleagues at work, friends, childhood teachers.
To the Ex-husband, I will ask him, how often he sees his wife mistakenly lose something, careless errors, or has difficulties keeping the appointment?
To the colleague at work, how often is the patient distracted from work activities and unable to follow simple directions?
To her friends: To tell me about patient social life, whether patient smoke and drinks?
To the Patient teacher: During your encounter with the patient, can you tell me any moment in your class that the patient was distractive, restless, and fidgety in class.
Physical Examination and Diagnostic Screening Test
It is imperative that clinician should incorporate an extensive health history during the initial encounter and to screen for difficulty with concentration, organization or establishing and maintaining a normal routine. PMHNP must know that ADHD patient will present with different symptoms which can mimic other mental health diseases and there is no laboratory or neurological test to aid in the diagnosing of ADHD (Katzman, Bilkey, Chokka, Fallu, & Klassen, 2017). A group of symptoms rating scales are used with organized interview assessment tools such as the Structures, Clinical interview doe DSM-IV axis 1 Disorder has proven significant when screening for ADHD (Adler&Shaw,2011).According to Katzman et.,2017, accurate diagnosis is possible with “Clinical interview as long as the interview establishes the four main diagnostic criteria: Early childhood-onset of the disorder, at least six of nine significant symptoms of inattention or hyperactivity meaningful impairment in at least two settings and symptoms peculiar to ADHD and not another psychiatric disorder”.
Differential Diagnoses
Attention Deficit Hyperactive Disorder (ADHD)
Generalizes anxiety disorder (GAD)
Depression
The most likely outward diagnosis is ADHD, the patient had verbalized having similar problems like those seen in her daughter diagnosed with ADHD. This is evidence that suggest that this patient has had ADHD since childhood that was not diagnosed, and it progressed to adulthood. Also, her report from first and second grade was poor, and her teacher’s comment suggested difficulties with attention and concentration at grade level. As an adult, the patient continues to exhibit difficulty mostly with attention, concentrating on tasks, keeping medical appointments, anxious, and stressed over her family situation. In addition, she exhibits symptoms that are suggestive of major depression. These symptoms will include irritability, trouble sleeping, constantly worrying about her family and work situation, emotional and overwhelmed. According to Stahl (2013), it is not unusual for adult patients diagnosed with ADHD to have other psychiatric disorders such as major depression, anxiety disorder, and substance abuse disorder.
Pharmacological agents
Methylphenidate (Ritalin XL) initially 20 mg/day orally in the morning for ADHD in adults. Mechanism of action is by inhibiting DAT and NET so that no reuptake takes place in the presynaptic neuron leading to increase dopamine and norepinephrine (Stahl, 2013). Intervention with Ritalin aims to reduce symptoms of inattentiveness, hyperactivity, and impulsiveness (Stahl, 2018).
Atomoxetine (Strattera) starting at 40mg/day, increasing to 80mg/day after seven days in the morning (Shier et al., 2012). Increase the dose to 100 mg/day after 2-4 weeks of therapy as tolerated. Strattera is a selective norepinephrine reuptake inhibitor (NRI) or NET inhibitor for ADHD in adults and children over six years old. Inhibiting NET increases both dopamine and norepinephrine in the prefrontal cortex. Although the first-line treatment for adult ADHD is stimulant like methylphenidate and amphetamine, my preference will be Atomoxetine (non-stimulant) because of the intolerable side effects and abuse potential or exacerbation of anxiety associated with stimulants (Shier et al., 2012). Also, there are compliance issues associated with multiple dosing of methylphenidate immediate-release tablets.
Therapeutic Changes
4, 8, 12 Weeks follow up-Following the initiation of amphetamine XR, it is expected that the patient should feel the therapeutic benefit of the medication. However, I would not have exceeded the 20mg approval maximum dose for an adult to decrease the adverse effect burden despite her stable vital signs. The development of jitteriness and anxiety are dose-related adverse effects. Side effect symptoms should abate by lowering the dose to the maximum approved.
16 Weeks follow up- The patient continued 20 mg/day but remained symptomatic. The goal of treatment should be complete remission of symptoms. Certainly, the treatment plan needs to be reevaluated, and if need be, her medication adjusted or evaluated for a comorbid condition. It is essential that the patient is counseled about noncompliance with a treatment regime. Based on the patient feedback, I might consider switching to another formulation of amphetamine or another ADHD agent. 20 Weeks and beyond follow up- Monitoring the patient is paramount as the prescriber continues to adjust the patient’s medications. Also, it is important to document all information pertaining to off-label medication use. Recognizing that another psychiatric comorbidity is present, and planning treatment accordingly is paramount.
Lesson learned
Prescribers must be aware that ADHD might coexist with other psychiatric comorbidities like major depression, anxiety disorder, and substance abuse in some patients. Patients must be involved in their plan of care to a large extent and report all adverse side effects associated with the treatment.
References
Adler, L. A., & Shaw, D. (2011). In Buitelaar, J. K., Kan, C. C., & Asherson, P. J. (2011).
ADHD in Adults: Characterization, diagnosis, and treatment (Edited). New York, NY: Cambridge University Press.
Katzman, M. A., Bilkey, T. S., Chokka, P. R., Fallu, A., & Klassen, L. J. (2017). Adult ADHD
and comorbid disorders: clinical implications of a dimensional approach. BMC psychiatry, 17(1), 302. doi:10.1186/s12888-017-1463-3
Shier, A. C., Reichenbacher, T., Ghuman, H. S., & Ghuman, J. K. (2012). Pharmacological
treatment of attention deficit hyperactivity disorder in children and adolescents: clinical strategies. Journal of central nervous system disease, 5, 1–17. doi:10.4137/JCNSD.S6691
Stahl, S. M. (2008). Essential Psychopharmacology Online. Retrieved October 23, 2019,
fromhttps://stahlonline-cambridge-org.ezp.waldenulibrary.org/prescribers_drug.jsf?page=9781316618134c77.html.therapeutics&name= METHYLPHENIDATE%20(D,L)&title=Therapeutics
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical
applications (4th ed.). New York, NY: Cambridge University Press.
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