THE ASSIGNMENT: 5 PAGES Examine Case Study: A Young Caucasian Girl with ADHD (CASE STUDY IS IN ATTACHED FILE WITH DECISION RESULTS) You will be asked to make three decisions concerning the medication

Attention Deficit Hyperactivity Disorder

A Young Girl With ADHD

BACKGROUND

Katie is an 8 year old Caucasian female who is brought to your office today by her mother and father. They report that they were referred to you by their primary care provider after seeking her advice because Katie’s teacher suggested that she may have ADHD. Katie’s parents reported that their PCP felt that she should be evaluated by psychiatry to determine whether or not she has the condition.

The parents give the PMHNP a copy of a form titled “Conner’s Teacher Rating Scale-Revised”. This scale was filled out by Katie’s teacher and sent home to the parents so that they could share it with their family primary care provider. According to the scoring provided by her teacher, Katie is inattentive, easily distracted, forgets things she already learned, is poor in spelling, reading and arithmetic. Her attention span is short, and she is noted to only pay attention to things she is only interested in. The teacher opined that she lacks interest in schoolwork and is easily distracted. Katie is also noted to start thing but never finish them, and seldom follow through on instructions and fails to finish her schoolwork.

Katie’s parents actively deny that Katie has ADHD. “She would be running around like a wild person if she had ADHD” reports her mother. “She is never defiant or has temper outburst” adds her father.

SUBJECTIVE

Katie reports that she doesn’t know what the “big deal” is. She states that school is “OK”-her favorite subjects are “art “ and “recess”. She states that she finds her other subjects boring and sometimes hard because she feels “lost”. She admits that her mind does wander during class to things that she thinks are more fun. “Sometimes” Katie reports “I will be thinking about nothing and the teacher will call my name and I don’t know what they were talking about.”

Katie reports that her home life is just fine. She reports that she loves her parents and that they are very good and kind to her. Denies any abuse, denies bullying at school. Offers no other concerns at this time.

MENTAL STATUS EXAM

The client is an 8 year old Caucasian female who appears appropriately developed for her age. Her speech is clear and logical. She is appropriately oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year, she demonstrates no noteworthy mannerism, gestures, or tics. Self-reported mood is euthymic. Affect is bright. Katie denies visual or auditory hallucinations, no delusional or paranoid thought processes readily appreciated. Attention and concentration are grossly intact based on Katie’s attending to the clinical interview and her ability to count backwards from 100 by serial 2’s and 5’s. Insight and judgement appear age appropriate. Katie denies any suicidal or homicidal ideations.

Diagnosis: Attention deficit hyperactivity disorder, predominantly inattention presentation

DECISION POINT ONE

Select what the PMHNP should do:

Begin Wellbutrin (bupropion) XL 150mg orally daily.
Begin Intuniv extended release 1 mg orally at bedtime.
Begin Ritalin (methylphenidate) chewable tablet 10mg orally in the morning.

Results of decision point one

client returns to clinic in four weeks
Katie’s parents reports that they spoke with Katie’s teacher who notices that her symptoms are much better in the morning, which has resulted in improvement in her overall academic performance. However, by the afternoon, Katie is “starring off into space” and “daydreaming” again
Katie’s parents are very concerned, however, because Katie reports that her “heart felt funny.” You obtain a pulse rate and find that Katie’s heart is berating about 130 beats per minute.

DECISION POINT TWO

Select what the PMHNP should do next:

Continue same dose of Ritalin and re-evaluate in 4 weeks.
Change to Ritalin LA 20mg orally daily in the morning.
Discontinue Ritalin and begin Adderall XR 15 mg orally.

Results of decision point two

Client returns to the clinic in four weeks
Katie’s academic performance has still improved and the switch to the LA preparation is lasting Katie throughout the school day.
Katie’s report of her heart feeling “funny” has gone away. Pulse was 92 during today’s office visit

DECISION POINT THREE

What should the PMHNP do next:

Maintain current dose of Ritalin LA and reevaluate in 4 weeks
Increase Ritalin LA to 30 mg orally daily.
Obtain EKG based on current heart rate.

GUIDANCE TO STUDENT

At this point, Katie’s symptoms are well controlled (her attention is sustained throughout the school day) and her side effects have gone away following change to a long acting preparation. There is no indication at this point that the dose should be increased as it is always advisable to use the lowest effective dose of stimulant medication. Katie’s heart rate is appropriate for a 8 year old girl and an EKG would not be indicated based on her heart rate