Due tomorrow please
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
Week 7: Grand Rounds Discussion: Complex Case Study Presentation
Student name: Pris
College of Nursing-PMHNP
PRAC 6675: PMHNP Care Across the Lifespan II
July 13, 2021
Objectives
The presentation will:
1. Describe a comprehensive patient history.
2. Explain the diagnostic results of the patient.
3. Explain the mental status examination findings of the patient and patient diagnosis.
4. Discuss the treatment options in managing a patient with ADHD.
Subjective:
CC (chief complaint): Jane, not her real name is a 7-year-old girl brought in by her mother. Her mother reports that Jane appears to be always “on the go” and appears to be “driven by a motor.” Jane’s mother also reports that she is very aggressive at home and school, threatens her mother and her siblings, is disrespectful to teachers and her mother, wets the bed each day, and bites her nails leaving marks on the tip of her fingers.
HPI: Jane’s mother reports that since she joined school, her behavior worsened because while at home, her elder brothers avoided interacting with her to avoid her tantrums. However, at school, Jane often got into trouble because she could not wait for her turn, had difficulties concentrating, lost her books often, could not follow instructions, and had difficulties sitting still. Jane stated, “I don’t want to go to school because I don’t like it. You always remind me to go to school and I hate you, you can’t control me. I don’t want to live anymore.” Jane’s mother reports Jane has been very manipulative by using threats, especially when her mother asked her to go to school or to bed early because she sleeps at 1 AM. Jane was afraid of ghosts and had to sleep with a night light-on. When in the dark, Jane states that she can see ghosts' shadows on the wall. Jane's mother says she is afraid of disciplining her because she would get nasty to her.
Substance Current Use: Jane’s mother reports that she does not abuse any substances, including alcohol, street drugs, or marijuana.
Medical History:
· Current Medications: Jane does not use any medications currently.
· Allergies: No known drug, food, or environmental allergies.
· Reproductive Hx: Jane has not started menstruating.
ROS:
GENERAL: No fever, chills, weight loss, or fatigue.
HEENT: Eyes: No blurred vision, visual loss, double vision, or yellow sclerae. Ears: No ear pain or discharge. No hearing loss. Nose: No nasal congestion, sneezing, or runny nose. Throat: No sore throat or dysphagia.
SKIN: No itching or skin rash.
CARDIOVASCULAR: The patient denies chest pain, chest discomfort, or chest pressure. No edema or palpitations.
RESPIRATORY: No shortness of breath, sputum production, or cough.
GASTROINTESTINAL: No nausea, vomiting, diarrhea, or anorexia. The patient denies abdominal pain or blood in stool.
GENITOURINARY: She denies burning on urination, urinary urgency or hesitancy, and urinary odor or odd color.
NEUROLOGICAL: The patient denies headache, syncope, dizziness, ataxia, paralysis, numbness, or tingling in the extremities. She also denies any change in bowel or bladder control.
MUSCULOSKELETAL: No back, muscle, or joint pain or stiffness.
HEMATOLOGIC: No bleeding, easy bruising, or anemia.
LYMPHATICS: No history of splenectomy or enlarged nodes.
ENDOCRINOLOGIC: The patient denies any history of polyuria, polydipsia, sweating, cold, or heat intolerance.
Objective:
Diagnostic results:
An electrolyte profile test was done and there were no electrolyte imbalances. According to Greenblatt & Gottlieb (2017), zinc, magnesium, and copper imbalances are known to cause ADHD symptoms. Mousain-Bosc et al., (2006) wrote that chronic magnesium deficiency is associated with hyperactivity, sleep disturbances, poor attention at school, and irritability.
Complete blood count was normal. According to Islam et al., (2018), iron is essential for cognitive function and brain development. Iron deficiency anemia is linked to alteration of neurotransmitters, which results in central nervous system disorders such as attention deficit hyperactivity disorder.
Liver function tests were normal. Evaluating liver function is essential before initiating treatment, considering that the patient’s most likely diagnosis is ADHD.
Thyroid function tests are normal: Albrecht et al., (2020) cite that children with hyperthyroidism are seven times more likely to have symptoms of ADHD.
Assessment:
Mental Status Examination:
Jane is a 7-year-old who appears her stated age. Dressed appropriately according to the occasion and weather of the day. She walks into the clinic while dancing. As she sits, she fidgets and rotates her chair. At some point, she stands up and walks to the window to stare. Her brother reminds her to be seated and answer the psychiatrist’s questions, and she cruelly bites him. As her mother attempted to discipline her, she screams and did exactly the opposite of what was required. Jane’s speech is normal rate but louder. Her mood is good, and her affect is appropriate. Although her thought process is goal-directed, there is evidence of difficulties in staying on a topic. Her thought content is free of delusions. However, she admits visual hallucinations while in the dark. Cognitively, the patient is alert and oriented x4. Her attention and concentration are impaired, while her memory is intact. She has good judgment with no insight. She denies suicidal or homicidal behavior, thoughts, or intentions.
Diagnostic Impression:
Attention-deficit hyperactivity disorder (ADHD)
Based on the patient’s stated symptoms, she is most likely suffering from ADHD. According to DSM 5, ADHD is a persistent pattern of hyperactivity-impulsivity or inattention that interferes with development or functioning. In the hyperactive-impulsive subtype of ADHD, patients must present with at least six of the following symptoms for at least six months:
1. Often fidgets with or taps hands or feet or squirms in a seat.
2. Leaving the seat in situations where he/she is expected to sit.
3. Running about or climbing in inappropriate situations.
4. Inability to play or participate in leisure activities.
5. Is often on the go and appears to be driven by a motor.
6. Talking excessively.
7. Blurting out answers before a question is completed
8. Trouble waiting for one’s turn.
9. Interrupting and intruding on others.
These symptoms should be present before the age of 12 and should be present in at least two settings and cause significant functional impairments in academic, social, or other important areas of functioning. They should not also be linked to other psychiatric illnesses such as oppositional defiant disorder (APA, 2013).
Jane demonstrates symptoms of ADHD, including fidgeting and squirming the chair, talking excessively, leaving the seat when she is supposed to be seated, she appears to be “on the go and driven by a motor,” has trouble waiting for her turn, and interrupts others. She also demonstrates symptoms of the inattentive subtype of ADHD, including losing her books and difficulty in concentrating at school.
Oppositional defiant disorder (ODD).
According to DSM 5 by APA (2013), oppositional defiant disorder is a pattern of anger or irritable mood, argumentative or defiant or vindictiveness behavior lasting at least 6 months.
Jane exhibits some of the symptoms of oppositional defiant disorder, including displaying anger and resentment often, as per her mother's report, arguing with her mother, and deliberately annoying her by doing exactly the opposite of what she is required to do. However, to diagnose a patient with ODD, they should have at least four symptoms, while Jane has only three symptoms of ODD.
Conduct disorder
Jane shows some of the signs of conduct disorder, including bullying and threatening her siblings, peers at school, and her mother. She also initiated a physical fight in the hospital with her brother. Although her mother states that these symptoms have lasted longer than six months and affect her social and academic functioning, she does not meet the DSM 5 criteria for conduct disorder (APA, 2013).
Reflections:
If I were to conduct the session again, I would seek the opinion of Jane’s teacher. In the interview, Jane's mother provided the patient's history. To diagnose ADHD, a patient must demonstrate symptoms in at least two settings (APA, 2013). I would also inquire about her developmental milestones, which are crucial in ruling out other disorders.
Jane is a minor, and her mother should consent to treatment. Although Jane is legally not capable of consent, it is crucial to seek her assent to improve her cooperation in treatment (Committee on Bioethics, 2016). Also, the therapist should uphold the ethical principle of beneficence by choosing the safest and most efficacious drug in managing Jane. All treatment options must have minimal harmful effects to prevent patient harm. The healthcare provider should also ensure patient confidentiality.
Patient and family education in managing Jane. Jane’s mother should be encouraged to communicate often with her teacher, keep a consistent daily schedule for daily activities such as eating and sleeping, reward good behaviors, ensure a healthy diet with all the required nutrients, limit environmental distractions, and ensure adequate sleep in the patient by embracing sleep hygiene. Importantly, Jane’s mother should be educated that Jane has ADHD, which needs treatment and prescribed medications should be taken as prescribed.
Case Formulation and Treatment Plan:
Plan
Ritalin LA 20mg PO taken in the morning. This is a long-acting stimulant medication. Ritalin is the first-line treatment option in managing ADHD because of its safety profile and efficacy. The long-acting formulation is associated with fewer side effects related to short-acting stimulants, including tachycardia and palpitations (Stahl, 2015). The alternative medication is Intuniv 1g PO to be taken every morning. Intuniv is a centrally-acting alpha-2 adrenergic receptor agonist. According to Bello (2015), alpha-adrenergic receptor agonists are used, particularly in treating the hyperactive-impulsive ADHD subtype.
The first-line psychotherapy approach for managing Jane is cognitive-behavioral therapy. According to Coelho et al., (2017), CBT interventions for ADHD include psychoeducation, parental training to enable parents to establish routines and healthy habits, use rewards, appreciate behaviors, and handle environments to ensure predictability for the patient. It also includes teaching the child about problem-solving, social skills, and emotional regulation. The alternative counseling approach is incorporating classroom management strategies that reward good behavior and using a daily report card.
The parameters for evaluation include the patient's social and academic functioning, sleep patterns, and problem-solving skills. Patient education includes the side effects of Ritalin LA such as headache, loss of appetite, dizziness, nausea, and weight loss.
Discussion prompt questions
1. How does DSM 5 categorize ADHD?
2. What pertinent information and diagnostic tools are crucial in diagnosing ADHD?
3. What are the long-term effects of ADHD in children?
References
Albrecht, D., Ittermann, T., Thamm, M., Grabe, H. J., Bahls, M., & Völzke, H. (2020). The association between thyroid function biomarkers and attention deficit hyperactivity disorder. Scientific reports, 10(1), 1-9.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publsihing.
Bello, N. T. (2015). Clinical utility of guanfacine extended release in the treatment of ADHD in children and adolescents. Patient preference and adherence, 9, 877. https://doi.org/10.2147/PPA.S73167.
Coelho, L. F., Barbosa, D. L. F., Rizzutti, S., Bueno, O. F. A., & Miranda, M. C. (2017). Group cognitive behavioral therapy for children and adolescents with ADHD. Psicologia: Reflexão e Crítica, 30.
Committee on Bioethics. (2016). Informed consent in decision-making in pediatric practice. Pediatrics, 138(2). https://doi.org/10.1542/peds.2016-1484.
Greenblatt, J., & Gottlieb, B. (2017). Finally Focused: The Breakthrough Natural Treatment Plan for ADHD That Restores Attention, Minimizes Hyperactivity, and Helps Eliminate Drug Side Effects. Harmony.
Islam, K., Seth, S., Saha, S., Roy, A., Das, R., & Datta, A. K. (2018). A study on association of iron deficiency with attention deficit hyperactivity disorder in a tertiary care center. Indian journal of psychiatry, 60(1), 131. https://dx.doi.org/10.4103%2Fpsychiatry.IndianJPsychiatry_197_17
Stahl, S. M. (2015). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
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