Assignment: Presentations of ADHD Case Study
Assignment: Presentations of ADHD Case Study
Case #2: ‘The scatter-brained mother whose daughter has ADHD, like mother, like daughter.’
According to studies, ADHD has a high prevalence in children. However, some adults have similarly shown the presence of the symptomatomatology of the condition. Studies have apportioned the existene of such subsyndromal evidence of ADHD in adulthood to the absence of diagnosis at childhood. Therefore, assessing and formulating pharmacological interventions for such patients become crucial for nurse practitioenrs. The purpose of the present paper is to examine the case of a mother with ADHD symptoms akin to her daughter.
Questions with their Rationale
- Are you aware of the whereabouts of your birth parents, and if yes, are they part of your present life? It is important to understand the whereabouts of the patient’s birth parents and whether they are involved in her life. This information will help the nurse track them down and get to know more about patient history. Their support will also help in managing patients ADHD.
- Is it ok if I speak to certain people in your life about your mental condition to help in formulating your treatment plan? The question will help the PMHNP get permission from the patient on whom to involve in the management of her current mental disorder so as not to violet her confidentiality (Flaskerud, 2012).
- Which symptoms affect you the most? It is very crucial to involve the patient in managing her mental condition rather than making it the decision of the PMHNP to decide what symptoms are most important to be treated first. In case of conflict in the treatment regimen, the PMHNP will thus have to educate and explain to the patient the course of treatment and the reasons behind her treatment choice.
People to Speak to in the Patient’s Life
It is important to speak to the adoptive parents of the patient to be able to gain more information on her childhood life. They will be required to respond to questions such as at what age did you start noticing the patients symptoms? Does any of his siblings ever have the same symptoms? Which action did you take to help the patient? What kind of medication was the patient taking to manage her symptoms? The patient’s schoolmates and teachers are also vital as they can give further information about how the patient used to behave in school, her performance and how she related to other students in the past. Her school mates will respond to questions such as, what kind of physical activities did she engage in a while at school? Was she relating well to her classmates? Was she likable? Her teachers, on the other hand, will be required to respond to questions such as how was her general performance? Was she active during class discussions? Did she accept punishment in case of any indiscipline behaviors at school? All this information will help the PMHNP understand the patient present mental status and recommend the best treatment plan to help manage her condition (Tolin et al., 2016).
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Physical Examination and Diagnostic tests
The PMHNP must perform a full physical examination to the patient including neurological examination in addition to mental status before making a diagnosis. Other lab tests such as a routine blood work should also be performed such as CMP and CBC to
make sure that her levels are within normal limits (Stahl, Grady, & Muntner, 2017). Additional lab tests should also be performed to rule out physical disorder that might cause similar symptoms such as vitamin B deficiency and TSH. Vitamin B12 deficiency is known to cause psychiatric, neurologic, mood and cognitive symptoms. Thymine deficiency, on the other hand, can also lead to cognitive deficits. Drug abuse and use of illicit drugs can also be ruled out as the causative agents of the patient’s symptoms by some lab tests such as urinalysis.
- ADD with GAD and SUD
From the patient’s history, and symptoms, this is the most preferred diagnosis. The American Psychiatric Association’s (APA) DSM-5 states that a patient can only be diagnosed with ADD upon having 6 or more symptoms which the patient meets (Tolin et al., 2016). The patient is reported to overlook and miss important details, has a problem staying focused, fond of losing things, does not follow instructions, distracted easily, forgetful of her routine daily activities and sometimes unable to maintain attention through conversations. She also displays symptoms of GAD such as difficulties in concentrating, excessive worry, unable to control her mood, easily irritable, sleep disturbances and excessively anxious. Her SUD is related to tobacco use as a result of smoking addiction.
- ADD with stress:
As pointed out in the above diagnosis, the patient meets the minimum DSM-5 criteria for ADD diagnosis. Additionally, studies reveal that stress can induce functional and structural changes in the hippocampus that affect an individual’s memory (Tolin et al., 2016). Consequently, stress negatively affects the way an individual learns due to an increased level of stress hormones in the brain which explains the poor patient performance at school.
- Specific Learning Disorder with GAD:
The DSM-5 criteria states that learning disorder is characterized by one or more of symptoms such as slow reading, trouble spelling, unable to comprehend what is being read, trouble writing, struggling with mathematical reasoning or having difficulties with calculations (Tolin et al., 2016). Consequently, the patient might present with low academic skills as compared to what is expected for a specific age, which must have started during the school-age years, and there are no symptoms of hearing or visual disorders. Together with GAD, the patient’s mental disorder can be explained.
- Quillivant XR 20mg OD in the morning, increase by 10-20mg (max 60mg/day) weakly: The PMHNP selected this medication as the first treatment for the patient given its prolonged duration of action permits for a daily dose rather than frequently administered alternatives three to four times a day. The patient is a single mother who is overwhelmed by taking care of her two kids and as such needs a drug that will help her concentrate through the day, and not a burden remembering when to take the medication. The mode of action of Quillivant is through blocking the dopamine and norepinephrine reuptake hence increasing the concentration of these two neurotransmitters in the brain (Cortese et al., 2017). An increased level of norepinephrine and dopamine in the brain will enhance the dorsolateral prefrontal cortex that will help improve the patient’s concentration and functioning through the day. Unlike other psychotropics, some of the effects of this drug will be realized immediately, while some may be reached at after several weeks of medication with minimum side effects.
- Bupropion XL 150mg OD in the morning: Bupropion is also a norepinephrine-dopamine reuptake inhibitor (NDRI), which is used as an off-label drug for the management of ADHD/ADD. The FDA has also approved it for the management of nicotine addiction (Kharasch et al., 2019). As such, an increase in the levels of norepinephrine and dopamine in the brain will help manage the patient’s symptoms of ADD and ADHD, besides, to help the patient quit smoking. The therapeutic response of this agent is expected within 2 to 4 weeks but might take up to eight weeks to fully manage the patient’s symptoms. The drug also has few side effects as compared to other NDRIs.
During the first, second and third visit by the patient after Adderall prescription, her symptoms improved as she was able to concentrate. The dose was however increased since her symptoms had not fully resolved. However, the increased dose resulted in side effects of jitteriness which she could not tolerate. The patient was nevertheless advised to go on with the current dose. The decision of adding another dose was reached at after the next visit. The patient was put on CBT coupled with the initial diagnosis which managed her symptoms adequately.
It is crucial for the PMHNP to realize that involving the patient in the treatment plan is very important for an effective outcome. Additionally, not all ADHD drugs will have the same effects in every patient (Stahl, Grady, & Muntner, 2017). The patient also needs to be closely monitored for various interventions to be made such as altering the dose or managing the side effects of a given drug. Lastly, the patients family must be involved in helping manage the symptoms of a patient who has any mental disorder.
Therefore, it is clear that even adutlts may suffer fro the symptoms of ADHD. Thus, in order to diagnose the condition, one will need to revisit their past lives and prsent ones by asking individuals such as their parents and friends pertinent questions for diagnosis. Also, ADHD may share symptoms with other conditions hence it becomes important to make a differential diagnosis. Such diagnosis plays an important role in determining the necessary pharmacological intervention.
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