Writer Choice
38693INITIAL DISCUSSION POST: Week 9
Case 1: Volume 2, Case #21: Hindsight is always 20/20, or attention deficit hyperactivity disorder
1. List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions?
1. “Do you sleep throughout the night and for how long?” Identifying this symptom can help determine if the patient is suffering from residual effects of Attention Deficit Hyperactivity Disorder (ADHD) or General Anxiety Disorder (GAD). Anxiety can produce fatigue and sleepless nights. This can help determine treatment (Mayo Clinic, 2017).
2. “Do you smoke or drink caffeinated beverages?” Both nicotine and caffeine can worsen anxiety (Mayo Clinic, 2017).
3. “What do you do when you are feeling anxious or short tempered with friends and family, how do you react?” Identifying a patient’s response when faced with these symptoms of anxiety can be helpful in identifying and breaking the cycle (Mayo Clinic, 2017).
2. Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
I would like to speak to the man’s wife to ask specifically what changes she notices when he is “anxious” and what leads up to these situations. As he has no children I would like to talk with a coworker to see if they notice changes in the patient’s behavior/temper and when that occurs. I would also like to talk with his psychiatrist and therapist to confirm what medication he has been on as well as any therapies he has undergoing, such as Cognitive Behavioral Therapy (CBT), Behavioral therapies and relaxation techniques (Zabaleta del Olmo, n.d.).
3. Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
Physical Exams: A physical exam itself to identify if the anxiety might be tied to an underlying medical condition or to medications. rule out medical reasons for depression, and to evaluate where he is at in regard to his BMI, HTN, etc.…
Diagnostic Tests: CBC to detect for cancer which can , TSH thyroid function test – hyperactivity can lead to anxiety, Blood Glucose – low blood sugars can lead to irritability and to anxiety Tox screen – misuse or withdrawal can lead to anxiety (Yu Dong, 2015).
4. List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
1. Adult Attention Deficit Hyperactivity Disorder (ADHD) with comorbid GAD * I feel this is the most likely diagnosis as the patient has suffered not only symptoms of generalized anxiety disorder , such as irritability and anxiety, he also reported having needed medication to “slow down” from. These symptoms are persistent. He needs continued treatment to address the continuing symptoms. Different factors can contribute to ADHD though an exact cause is not known. (National Institute, 2016).
2. General Anxiety Disorder (GAD) include symptoms of irritability along with anxiety. This is a possible diagnosis which could have been caused by a stressful event such as the childhood experience of growing up with the abusive father with Alcohol Use Disorder (AUD) (National Institute, 2016).
3. Post-Traumatic Stress Disorder (PTSD) Symptoms normally include being on edge, jumpy, and having angry outbursts. Though John had not been diagnosed with PTSD, it could have been missed, and I think this is a possibility based on his experience with his father growing up, but of the three this is the least likely in my opinion based on his symptoms and presentation. . (National Institute, 2016).
5. List two pharmacologic agents and their dosing that would be appropriate for the patient’s ADHD Therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
1. Duloxetine (Cymbalta) initial dose of 60 mg/day, up to a max dose of 120 mg/day. It functions by boosting neurotransmitter serotonin, norepinephrine/noradrenaline, and dopamine. The goal of this medication is to achieve remission of the symptoms of anxiety and irritability. (Stahl, 2008).
2. Wellbutrin (Bupropion) starting at 75 mg twice daily, increasing to 100 mg twice daily, then to 100 mg 3 times daily; maximum dose 450 mg per day. It blocks neurotransmitters norepinephrine and dopamine. The goal again would be to reduce the symptoms of anxiety and irritability, the Bupropion would be an additive with these symptoms (Stahl, 2008).
6. If your assigned case includes “check points” (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.
6-year follow up – I would want to increase or initiate something to address the client’s increased agitation (such as Citalopram) and perhaps decreasing many meds that can cause agitation as a side effect, such as Cymbalta.
7. Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations. The lessons learned include the understanding that GAD and symptoms of GAD can be treated indifferent ways. Over time efficacy of treatments can weaken and different or augmentative treatments may be required for to treat illness that have become resistant to treatments that have been effective in the past.
References
Mayo Clinic (2017). Generalized anxiety disorder. Symptoms & Causes. Retrieved from https://www.mayoclinic.org/diseases-conditions/generalized-anxiety-disorder/symptoms-causes/syc-20360803
National Institute of Mental Health (NIH) (2016). Attention Deficit Hyperactivity Disorder. Retrieved from https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml
Stahl, S. M. (2008). Essential Psychopharmacology Online. Retrieved May 30, 2018 from
https://stahlonline-cambridge-org.ezp.waldenulibrary.org/essential_4th.jsf
Yu Dong, Fatima Noorani, Rushi Vyas, Chandrika Balgobin, Vanessa Torres-Llenza, & Catherine Crone, (June 30, 2015). Managing Anxiety in the Medically Ill. Psychiatric Times Vol 32 (1). Retrieved from http://www.psychiatrictimes.com/special-reports/managing-anxiety-medically-ill
Zabaleta del Olmo, E., Lopez-Montoyo, A., Montero-Marin, J., Garcia-Campayo, J., Lopez-Montoyo, A., Zabaleta-del-Olmo, E., & Cuijpers, P. (n.d). Is cognitive-behavioural therapy more effective than relaxation therapy in the treatment of anxiety disorders? A meta-analysis. Psychological Medicine, 48(9), 1427-1436.
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