30.Wk9DisRes

Jane,

I just need a discussion response to each of these 2 posts. I will post their case studies as well. Thanks!

Post a response to the following:

· Provide the case number in the subject line of the Discussion.

· 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.

· 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.

· Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.

· List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.

· 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.

· 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.

· 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.

peninah 

Volume 2 Case 21: Hindsight is always 20/20 or Attention Deficient Hyperactive Disorders

COLLAPSE

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Hindsight is always 20/20, or attention deficit hyperactivity disorder

31-year-old man with a chief complaint of anxiety of “different types” • Patient states that he “has been successful in graduate school, has financial worries, but states that he worries and is tense most of the time”.

Questions/Rationale for Patient

· What triggers your anxiety?

Rationale: This question helps gather baseline information to determine if the patient recognizes the factors that triggers his anxiety.  Knowing the triggers can help the patient foresee and combat the anxiety before it gets worse.

· What decreases the anxiety?

Rationale: The patient’s knowledge of how to reduce the feeling of anxiety by having the coping skills, would be a tool for a better quality of life.  Determining how to reduce the condition helps the patient participate in his own treatment, to achieve better outcomes.

· What is your current anxiety level on a scale of 0 – 10?

Rationale: This is an important question to determine the condition that the patient is currently in when this interview is taking place.  This helps the provider know the level of anxiety that the patient considers to be high and low, and if they took any medication or used any coping skills prior to the visit.

 

Questions to ask the Family

 

Patient’s wife

 

1.      What changes do you notice when your husband is at the peak of his anxiety?

 

Rationale:  Getting the wife’s take is important to get a history of changes in behavior that may be affected during periods of anxiety.  The patient may not be aware of these changes himself, so a close associate would be the best resource for this.

 

2.      Has your husband been fully compliant with his medication regimen?

 

Rationale: This is a very important question to determine compliance of the patient’s regimen. Knowing whether the the patient is taking his medication as ordered would determine if the provider needs to educate of importance of compliance or review and revise the medication (Hamed et al., 2015).

 

3.      When did this disorder start and what triggered it?

Rationale: The patient’s spouse would be a good historian when the husband started to experience anxiety and what caused it. It is important for the provider to understand the source of his anxiety, in order to treat the patient holistically.

 

Physical Exams and Diagnostic Testing

 

It is important to begin the interview by gathering good data regarding the history of his condition, is it chronic, intermittent, triggers, initial attack.  Determining whether the medication regimen is working is essential to his treatment; has he engaged in any non-pharmacological treatments like Cognitive Behavioral Therapy? (Danielson et al., 2018).

 

Tests that can be done include:

 

Thyroid Stimulating Hormone test- This test is important because hyperthyroidism may have similar symptoms as anxiety and should be ruled out (Ströhle et al., 2018).

 

The Vanderbilt Assessment Scale – A 55 question assessment to check for ADHD and other disorders such as oppositional-defiant disorder, anxiety, and depression.

 

Differential Diagnosis

1. Generalized Anxiety Disorder

With the display of symptoms including restlessness, financial worries, difficulty concentrating that effect daily functioning, it is possible that GAD is a possible diagnosis. Chronic anxiety symptoms for a long time get in the way of activity of daily living and can affect the patient’s health outcome

1. Trauma

Trauma can cause many similar symptoms that are exhibited in ADHD. Such symptoms include difficulty concentrating, difficulty sleeping, disorganization, hyperactivity, and can be seen in both conditions

1. Post-Traumatic Stress Disorder (PTSD)

Both PTSD and ADHD are accompanied by symptoms such as increased worry that does not wade, agitation and irritability, lack of concentration.

1. Panic Disorder

The patient displays symptoms of anxiety and panic disorder with difficulty breathing, nausea, diaphoresis.

 

Medications

 

Stimulants such as methylphenidate (Ritalin 2.5–5 mg/dose twice daily), and amphetamine (Adderall 5 mg BID), are best for ADHD, and work to increase norepinephrine and dopamine neurotransmission in the brain. Methylphenidate works by stopping the presynaptic dopamine transporters of central adrenergic neurons and the Amphetamines increases the release of catecholamine to increase the release of dopamine, which helps the patient have a better environmental response (Martinez-Raga et al., 2017).

Lessons Learned

 

            As an advanced nurse practitioner, it is important to base treatment on comprehensive data from the patient and other contacts close to him.  To treat the patient, it is important to consider all possible diagnoses before prescribing medication and recommending non-pharmacological treatments such as CBT and DBT (Coghill & Seth, 2015).

 

References

Coghill, D., & Seth, S. (2015, November 19). Effective management of attention-deficit/hyperactivity disorder (ADHD) through structured re-assessment: the Dundee ADHD Clinical Care Pathway. Child and adolescent psychiatry and mental health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4652349/.

Danielson, M. L., Bitsko, R. H., Ghandour, R. M., Holbrook, J. R., Kogan, M. D., & Blumberg, S. J. (2018). Prevalence of Parent-Reported ADHD Diagnosis and Associated Treatment Among U.S. Children and Adolescents, 2016. Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5834391/.

Hamed, A. M., Kauer, A. J., & Stevens, H. E. (2015, November 26). Why the Diagnosis of Attention Deficit Hyperactivity Disorder Matters. Frontiers in psychiatry. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4659921/.

Martinez-Raga, J., Ferreros, A., Knecht, C., de Alvaro, R., & Carabal, E. (2017, March). Attention-deficit hyperactivity disorder medication use: factors involved in prescribing, safety aspects and outcomes. Therapeutic advances in drug safety. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5367662/.     

Ströhle, A., Gensichen, J., & Domschke, K. (2018, September 14). The Diagnosis and Treatment of Anxiety Disorders. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6206399/.

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Hung

Case #14 The scatter-brained mother

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Case #14 The scatter-brained mother whose daughter has ADHD, like mother, like daughter.

List 3 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.      Have you ever been diagnosed with any mental disorders?

According to Pehlivanidis et al, (2020) ADHD mostly start in childhood.  Asking this question will enable me to understand the patient’s history and help in identifying any underlying conditions that may occur alongside her ADHD.

1. Are your parents involved in your life?

It is important to know if the client’s parents are part of her life.  She is a single parent and having a good support system (parents, friend, co-workers) will help to improve her outcome.  The more support she has the more likely she will be able to maintain therapy.

1. Have you ever thought of killing yourself?

              There is a strong comorbidity between mood and anxiety disorders.  Among patient with major depressive disorder (MDD) anxiety disorders such as social phobia, panic disorder and GAD.  GAD is thought to              being related to MDD (Maes, et al. 2018).

 

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.

· The first people I would like to talk to would be the client’s adoptive parents.  I would ask them if the client had any social, physical, or emotional issues growing up.  

              It would be important to speak to the client’s adoptive parents to understand how she was growing up and how she did in school.  It the parents did notice any behavioral disorders then did they seek treatment.  If so, what kind of                            treatments were done. 

· If possible I would like to speak with the client’s biological parents or siblings.  I would ask them specifically if they suffered from any mental disorders.

               May mental disorder have a genetic component.  Knowing if her biological parent or siblings had any mental disorders could help with diagnosing any comorbid disorders the client might have.

· I would like to talk to the client’s daughter.  I would ask the daughter what her mother is like at home.

Talking to the daughter will give me insight into what behaviors the client presents at home and how she deals with stress.  ADHD patient are usually disorganized, distracted, make careless mistakes, and stressed (Asherson, Buitelaar, Faraone, & Rohde, 2016).

Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.

It would be important to perform a physical exam that would include mental status exam and neurological exams.  Blood work such as a CBC and CMP to ensure that she is healthy before she is prescribed medications.  TSH would be important to rule out any thyroid issues.  Vitamin B (thiamine) deficiency can cause cognitive, psychiatric, mood, and neurologic symptoms (Gibson, et al, 2016).

 

List three differential diagnosis for the patient.  Identify the one that you think is most likely and explain why.

· ADHD

· GAD

· BIPOLAR

I believe that the client has ADHD with GAD.  For a person to be diagnosed with ADD they have to have six or more symptoms, which the clients have met.  She is disorganized, misses appointments, feels overwhelmed, hard time keeping a regular schedule and loses things.  Her GAD is characterized by her excessive worrying, sleep disturbances, and irritability (Stahl, 2013).

 

List two pharmacological 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.

· Quillivant XR 20mg daily in the morning and increase weekly by 10-20mg (max 60mg/day).  I believe that this medicine is best suited to help the client.  She has shown in the past that she is tolerant to Methylphenidate.  This formulation is an extended release which has a 12-hour duration rather than the 4-6-hour action of older formulations (Stahl, 2014b).  By blocking norepinephrine and dopamine’s reuptake it increases the quantity of those neurotransmitters to enhance the dorsolateral prefrontal cortex and improves concentration and attention (Stahl, 2013).  The effects can be immediate and optimum therapeutic level may take several weeks to achieve remission (Stahl, 2014b).

· Benzodiazepines (alprazolam) is prescribed for GAD, panic disorder, and anxiety associated with depression.  Alprazolam XR can be started at 0.5-1 mg/day in the morning and increased by 1mg/day every 3-4 days until desired effect (Stahl, 2014b).  Alprazolam XR may be less sedating than immediate-release formulations.  It is a very useful adjunct to SSRI and SNRIs in treating anxiety disorders (Stahl, 2014b). 

 

Lesson learned

Family history is an important determinant in ADHD, and can occur in adults which can lead to other mental health conditions such as GAD.  Not all medications will work the same on all patients. It is important to allow time for medication to work and reach therapeutic levels before changing medications.  Adjunctive medications may be a good alternative if applied appropriately. 

 

References:

Asherson, P., Buitellaar, J., Faraone, S. V., & Rohde, L. A. (2016).  Adult attention-deficit hyperactivity disorder:  key conceptual issues.  The Lancet Psychiatry, 3(6), 568-578.

Gibson, G. E., Hirsch, J. A., Fonzetti, P., Jordan, B. D., Cirio, R. T., & Elder, J. (2016).  Vitamin B1 (thiamine) and dementia.  Annals of the New York Academy of Sciences, 1367(1), 21-30.

Maes, M., Bonifacio, K. L., Morelli, N., R., Vargas, H. O., Moreira, E. G., St. Stoyanov, D., Barbosa, D. S., Carvalho, A. F., & Nunes, S. O. (2018).  Generalized anxiety disorder (GAD) and comorbid major depression with GAD are characterized by enhanced Nitro-oxidative stress, increased lipid peroxidation, and lowered lipid-associated antioxidant defenses.  Neurotoxicity Research, 34(3), 489-510.

Pehlivanidis, A., Papanikolaou, K., Mantas, V., Kalantzi, E., Korobili, K., Xanaki, L, Vassiliou, G., & Papageorgiou, C. (2020).  Lifetime co-occurring psychiatric disorders in newly diagnosed adults with attention deficit hyperactivity disorder (ADHD) or/and autism spectrum disorder (ASD).  BMC Psychiatry, 20(1), 1-12.

Stahl, S. M. (2013).  Stahl’s essential psychopharmacology:  Neuroscientific basis and practical applications (4th ed.).  New York, NY: Cambridge University Press.

Stahl, S. M. (2014b).  The prescriber’s guide (5th ed.).  New York, NY: Cambridge University Press.

 

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