adhd

Week 9: (ADHD)

College of Nursing-PMHNP, Walden University

NRNP 6665: PMHNP Care Across the Lifespan I

Faculty Name

April 30th , 2021

ADHD

Subjective:

CC (chief complaint): ‘his hyperactivity has increased and he is unable to focus after midday”, reported by the mom.

HPI: J.S is a 6 years old caucasian who presented with his mum for medication management. Patient was started on Ritalin 5mg in the morning about 4 weeks ago. The mum reported that the medication is effective up until midday. Patient loses concentration afterwards and becomes very hyperactive.

Past psychiatric history- Patients have a history of ADHD. ADHD was properly diagnosed about 4 week ago. No prior psychiatry illness or hospitalization.

Medication trials and current medications- Ritalin 5mg in the morning for ADHD

Psychotherapy or previous psychiatric diagnosis- No history previous psychotherapy or prior psychiatric hospitalization. During this visit, the patient and the mother were educated on a healthy living lifestyle. Helping the the child to organize his life and also limiting distraction

Pertinent substance use- Patient denies any substance use. Denies any history of substance abuse. The mother denies substance use during pregnancy

Family psychiatric/substance use. The patient lives with both parents in their home in the suburbs. Patient was born at 40 weeks gestational age via SVD. No history of sexual abuse.No known substance abuse in the family. No known family psychiatry history.

Social History- Patient lives with both parents. Patient has two older siblings male and female (18 and 12 respectively). They all live together with their parents. Patient has a fair relationship with his siblings. He sometimes gets into an argument with them. He is very active with a good appetite. He is grade 1 and attend IEP programe

Allergies- No known allergies

Medical History: No medical history.

Current Medications: Ritalin 5mg in the morning and Ritalin 2.5mg at 1pm

Reproductive Hx: ROS:

Vitals: BP 111/72, P- 66,T-96.8, R- 16, Spo2-98% in room air

GENERAL: No fever, chills, weakness, or fatigue and no weight loss

· · HEENT: Head is Normocephalic and atraumatic, Eye- pupils are equal, no discharges, No double, blurred vision. Ear, Nose, and Throat -No hearing loss, No congestion, no sore throat, and no sneezing

· · SKIN: Skin is warm, No rash or itching

· · CARDIOVASCULAR: No chest pain, No chest pressure, and no edema, No palpitation

· · RESPIRATORY: No respiratory distress.

· · GASTROINTESTINAL: No distension noted, No anorexia and vomiting

· · GENITOURINARY: No burning on urination

· · NEUROLOGICAL: The patient is alert and oriented, no dizziness, numbness, or tingling sensation of the extremities

· · MUSCULOSKELETAL: No muscle pain, No back pain, nobody stiffness, no edema noted

· · HEMATOLOGIC: The patient is not frail and no bleeding

· · LYMPHATICS: No enlarged lymph nodes.

· · ENDOCRINOLOGIC: No reports of polydipsia. No report of sweating or heat intolerance.

Objective:

Diagnostic results: School history and the teachers report was used to evaluate the patient for the diagnosis.

Assessment:

Mental Status Examination: He is a 6year-old caucasian male who looks his stated age. He is alert and orientated to time, place, person and situation. Patient was very jumpy and very hyperactive. He was inattentive and was unable to respond to most questions. He is neatly groomed and clean, dressed appropriately.The mother reported that he was not medicated that morning . per mother’s report, the patient is calm and focused till midday. Patient does not seem to focu le to stay on his seat. The mother reported he is getting to be more independent. The mother reported that IEP is progressing and she thinks he is where they want him to be. the patient was unabat and There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. the patient sometimes blurts during the assessment making request. Patients are easily distracted with short attention spans. lack of organization was also noted There is no evidence of looseness of association or flight of ideas. His mood is euthymic and hyperactive. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is poor. His insight is good.

Case Formulation and Treatment Plan:

 

Diagnostic Impression

According to DSM-5, the patient showed signs and symptoms of Attention deficit/ hyperactivity disorder, Hyperactivity and impulsivity type. ADHD is a disorder characthis Reflections Notes

Plan

References

Abdel-Basset, M., Mohamed, M., Elhoseny, M., Chiclana, F., & Zaied, A. E. N. H. (2019). Cosine similarity measures of bipolar neutrosophic set for diagnosis of bipolar disorder diseases. Artificial Intelligence in Medicine, 101, 101735.

Betzler, F., Stöver, L. A., Sterzer, P., & Köhler, S. (2017). Mixed states in bipolar disorder–changes in DSM-5 and current treatment recommendations. International journal of psychiatry in clinical practice, 21(4), 244-258.

Carmassi, C., Bertelloni, C. A., Cordone, A., Cappelli, A., Massimetti, E., Dell'Oste, V., & Dell'Osso, L. (2020). Exploring mood symptoms overlap in PTSD diagnosis: ICD-11 and DSM-5 criteria compared in a sample of subjects with Bipolar Disorder. Journal of Affective Disorders, 276, 205-211.

Young. T, (2018). What is the best treatment for Bipolar depression? Journal of psychiatry and Neuroscience. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3876031/

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer

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