Discussion Response to colleague:Allora M

Objectives

1. Evaluate patient symptoms and current presentation.
2. Analyze symptoms and compare and contrast similar disorders.
3. Develop a list of differential diagnoses.
4. Create an appropriate treatment plan.

Subjective:

CC: “Bad behavior.”

HPI: 9-year Caucasian female presents with her mother. Her mother reports over-the-top hyperactivity and cannot sit still for more than a few minutes. She reports that when she gets upset or does not get her way, she will kick, scream, and break things around the house. She even threatened to kill her brother earlier this year because she became so mad at him. Her mother reports that she has recently noticed that if the tv or music is too loud, she has tantrums and waves her hands until the volume is turned down. She states this behavior has been going on since she was little but has worsened recently. Her mother also reports she rarely talks; when she does, it is only when she is very angry or wants something. Her mother says she has trouble getting her to do anything other than stay on her iPad; she refuses to do homework or chores around the house and will have tantrums if made to do anything. Her mother also says that she has difficulty making friends and has a history of being bullied and stays in trouble at school because she is either making sounds, will not stay seated, or is not paying attention, and a lot of the time, she fails homework or test because of silly careless mistakes or forgetting to turn in her work. Her mother also says she is easily distracted and has to be told the same thing multiple times. Her appetite is good, and she has been eating more recently. She also has difficulty falling asleep at night. She has no history of SI but will bite her nails until they bleed when she gets very mad.

Social History: She was born three weeks early and raised in north MS. She lives with both of her parents and has one brother. She is the oldest child. Her mother reports some of her milestones were delayed, but the PCP said it was nothing to worry about. She was homeschooled until last year but transferred to a public school where she could not keep up her homework or grades, so she has to repeat the third grade this year. At home, she spends most of her time on her iPad, watching the same paw patrol video repeatedly, and likes to color. She does not like leaving the house. She has one friend but only gets to see her at school. Her mother denies any history of trauma or abuse. There are many guns in the home, but not all of them are locked up. She wears a seatbelt when riding in a car. Fire alarms are in all areas of the house.  

Substance Current Use: None

Family Substance Use: None

Psychiatric History: None

Family Psychiatric History:

• Mother- ADHD, anxiety, depression
• Father- PTSD, ADHD

Medical History: Born premature, spent one week in NICU, goes to speech therapy.  

• Current Medications: 13 mg CBD gummy po qhs to relax/sleep
• Allergies: None
• Reproductive Hx: no menstrual cycle, not sexually active

ROS:

• GENERAL: No changes in weight or sleep
• HEENT: wears glasses
• SKIN: No problems
• CARDIOVASCULAR: Denies any problems
• RESPIRATORY: Denies any problems
• GASTROINTESTINAL: increased appetite
• GENITOURINARY: Denies any problems
• NEUROLOGICAL: Denies any problems
• MUSCULOSKELETAL: Denies any problems
• HEMATOLOGIC: Denies any problems
• ENDOCRINOLOGIC: Denies any problems

Objective:

Vitals: BP: 118/68, HR: 89, RR: 18, HT: 4’5″, WT: 107, BMI: 26.75

Diagnostic results:

• Mood and Feelings Questionnaire: Parent report: no presence of depression
• Vanderbilt Assessment Scales- scored high on parent and teacher form for ADHD combined type.
• Drug screen negative

Assessment:

Mental Status Examination: 9-year-old Caucasian female is well-groomed, clean, dressed appropriately for the season and situation, and appears her stated age. Her affect and mood were appropriate. Eye contact was fleeting, and she would not speak during the visit. To communicate, she would point or nod her head at her mother. Her thought process and content could not be assessed at this time, but she did not appear to be responding to internal stimuli. There were no abnormal motor movements observed. However, she ran around the office, jumped on the couch, and needed frequent redirected to calm down or not to touch things. She was easily distracted and would frequently stop what she was doing to go look at something else or look out the window. When sitting, she did constantly bounce her knees or move around and pick at her fingernails.

Diagnostic Impression:

• Attention deficit hyperactivity disorder, predominantly inattentive F90.0
• The patient has difficulty paying attention, is easily distracted, does not seem to listen when someone is talking to her, fails homework over careless mistakes, or does not want to do homework or chores. She is also hyperactive, fidgets when she does sit down, and her mother and father both have been diagnosed with ADHD. Chen et al. (2019) report that ADHD is heritable, and having parents or other first-degree family members with it places a person at higher risk for developing it.
• Autism F84.0
• The patient exhibits symptoms such as behavioral problems, communication, and social deficits, with stereotyped movements when upset. Lau-Zhu, Fritz & McLoughlin (2019) state that symptoms of ADHD and autism do have overlapping symptoms. So, psychological testing needs to be performed before an autism diagnosis can be made to assess for more symptoms/deficits. Until more testing is done, ADHD is a more appropriate diagnosis.
• Disruptive mood dysregulation disorder F34.81
• DMDD was selected as a differential because the patient is easily irritable, has temper tantrums where she screams and breaks things, and has outbursts frequently throughout the week. However, Lane & Reynolds (2019) state that overstimulation in an ADHD person can cause anxiety and behavioral responsivity, and currently, her symptoms can be better described through a diagnosis of ADHD.

Reflections:

            If the visit could be repeated, I would not do anything differently. For now, we received enough information about the patient to start treating symptoms. An ethical consideration when treating this patient is autonomy and dignity. Even though the patient refuses to participate or speak during the visit, the provider should still speak, ask questions, educate the patient, and encourage participation in her own care. A legal consideration would be following clinical guidelines. Clinical guidelines are created to ensure that patients receive safe and evidence-based treatments. Straying away from those guidelines can place the patient at risk of harm. So to prevent possible legal problems, the provider should be educated on age-appropriate treatment options and guidelines for this patient.

            To promote the patient’s health, the provider can educate the family. The patient’s parents work full-time factory jobs and can not take off work often, and the patient’s grandmother does not have a vehicle at this time. The provider can educate the patient on Medicaid transportation so that the patient can make all her visits. To promote the patient’s safety and the safety of others, the provider can educate the family on the importance of locking up all guns so that the patient can not get a hold of them.

Case Formulation and Treatment Plan:

• Start methylphenidate CD 10 mg PO biphasic 30-70 capsule, extended-release, once daily, dispense #14, no refills

• Methylphenidate was selected since it is a stimulant, and Mechler et al. (2022) report that stimulates are first-line medications for ADHD. The patient’s parents also have taken methylphenidate without any negative side effects and report the medication worked well for them. So, methylphenidate was selected as her first medication.
• Refer for psychological testing for autism.
• Chahin et al. (2020) state that psychological testing can measure intellectual abilities, communication, and social interactions and identify autism and its severity. Further testing is needed to assess symptoms before a diagnosis is made. Also, where we live, many programs for special needs children and schools will not accept an autism diagnosis without psychological testing.
• Discussed CBT therapy, but the patient’s mother declined the referral due to transportation issues and inability to get off work.
• CBT can help teach the patient how to identify negative thought processes that can affect behavior and teach skills to form more positive thought processes, which can improve their behavior. Riise et al. (2020) state that CBT is an effective treatment option for people who have external behavioral problems.
• Educated on requesting intellectual/learning disability evaluation through the school district before school starts.
• Educated on medication and side effects.
• Educated on the importance of a healthy balanced diet and exercise.
• Given the office number and email address, and hours, the office is open.
• Educated on when to seek emergency services and given emergency numbers.
• Follow-up is scheduled for two weeks.

Discussion Questions:

1.) Do you agree with the diagnosis and plan of treatment at this time?

2.) Do you recommend any other screening tools or testing to help evaluate this patient?

3.) What would you recommend as the next step in treatment if improvements are seen or not seen?

PRECEPTOR VERIFICATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek-approved clinical site during this quarter’s course of learning.