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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
Week (enter week #7 ): Grand Rounds Discussion: Complex Case Study Presentation: ADHD
Angele Patricia Lemanga
College of Nursing-PMHNP, Walden University
PRAC 6675: PMHNP Care Across the Lifespan II
Dr. Elizabeth Connole-pond
07/13/2022
Objectives
1- To identify three different diagnoses with supporting evidence, listed in order from highest priority to lowest priority.
2- To understand the DSM-5 criteria for ADHD, Bipolar Disorder, and Generalized Anxiety Disorder.
3- To develop an appropriate care plan for the patient in the presented case including pharmacological and non-pharmacological interventions.
Subjective:
CC (chief complaint): “My daughter is irritable and blows up frequently. She cannot stay still, doesn’t pay attention in school, and has poor grades.”
HPI: MT is a 14-year-old African American female with a past psychiatric history of ADHD who was referred to the clinic by her pediatrician for psychiatric evaluation. The patient and mother were seen at the clinic for initial evaluation. MT was diagnosed with ADHD two years ago, and the mother declined pharmacological treatment. Then, MT started on psychotherapy for anger management and social skills, but she was not consistent with therapy sessions due to her mother’s work schedule conflict. According to her mother, MT does not share her feelings, and sometimes she will explode in anger. Recently she punched a hole in the walls on two occasions. She gets irritated when she is asked to complete house shores like washing dishes, cleaning her room, or organizing things. She will either start crying or hit the wall. MT mother is concerned about her daughter behavior because MT father has bipolar disorder and she wanted to know at which point MT could be affected by the same or similar condition. MT denies feeling depressed or losing interest in her pleasurable activities. She has been self-isolated from her friends, and sometimes, from her family. MT stated: “Sometimes I just don’t want to be bothered”. MT denies suicida/homicidal ideations. She also denies hearing voices or seing things that are not there.
Medications Trial: None
Psychotherapy or Previous psychiatric diagnosis: MT has a psychiatric history of ADHD. She is enrolled in psychotherapy for anger management and social skills.
Substance Current Use: MT denies smoking, drinking alcohol, or using illicit drug.
Medical History: None
· Current Medications: None
· Allergies: No known Drug, Food, or environmental allergy.
· Reproductive Hx: First menses at 13 y/o. Regular menses. Never been pregnant. Denies being sexually active. She is single and has no children.
Psychosocial History: MT is a 9th-grade student who lives with her mother and younger brother in a townhouse in Bowie, Maryland. She enjoys reading and playing card games. She denies having any legal issues. She denies any history of trauma or abuse. MT denies using illicit drug, alcohol, or smoking. She reports poor grades in school and a lack of interest in school activities.
General Statement: MT is a 14-year-old African American with a history of ADHD, not on medication but currently managed with psychotherapy. She has never been hospitalized. She denies suicidal/homicidal thoughts. ST is alert and oriented to person, time, place and situation.
Family Psychiatric/Substance Current Use:
– Father: Bipolar Disorder
– Mother: Depression, Anxiety
– Brother: ADHD
ROS:
• GENERAL: No chills, subjective fever, night sweats, weight loss.
• HEENT: No headache, vision changes, eye pain, sore throat.
• SKIN: No rashes, lesions, jaundice, bruising
• CARDIOVASCULAR: No chest pain, palpitations, syncope.
• RESPIRATORY: No SOB, coughing, orthopnea, wheezing.
• GASTROINTESTINAL: No n/v/d, abdominal pain, bloody stool, melena.
• GENITOURINARY: No frequency, dysuria, or hematuria.
• NEUROLOGICAL: No sensation/strength deficits. Endorsed inattention,
impulsivity, fidgeting, and difficulty following instructions.
• MUSCULOSKELETAL: No joint aches, pain, swelling
• HEMATOLOGIC: Denies anemia, bruising, or recent blood loss.
• LYMPHATICS: Denies swelling of lymph nodes or pain.
• PSYCHIATRIC: Denies visual/auditory hallucination, SI, HI.
• ENDOCRINOLOGIC: Denies increased thirst, excessive sweating, heat,
or cold intolerance.
Objective:
Diagnostic results:
· Connor’s parent and teacher rating scales for ADHD
· Swan rating scale (helps differentiate the types of ADHD) (Magnus et al., 2021).
· L aboratory test to rule out any medical condition:
CBC with differential, CMP, lipid panel, drug and alcohol level test, LFT, TSH, free T4,
Hep C, Hep B antigen, HIV, urinalysis, pregnancy test.
Assessment:
Mental Status Examination: MT is a 14-year-old African American female who presents for a psychiatric evaluation. The patient is alert and oriented to person, time, place and situation. She looks her stated age. Patient is well nourished, appropriately groomed and dressed for the season and situation. Her gait is steady. Her affect is neutral, and her mood is euthymic. MT speech is soft with regular tone and volume. Her thought process is goal-directed. Her memory is within normal limit. MT denies suicidal and homicidal ideations. She also denies visual and auditory hallucination. MT is unable to remain still and maintain eye contact during interview.
Diagnostic Impression:
1. Attention Deficit Hyperactivity, predominantly inattentive (HDHD) (F90.0)
ADHD is a psychiatric disorder that affects children’s functioning potential and can last throughout adulthood if not managed adequately. Affected patients demonstrate inappropriate developmental levels of impulsivity, hyperactivity, and inattentiveness. The manifestations begin at a young age and typically present as being forgetful, difficulties in completing tasks, lack of concentration, lack of attention, interrupting during a conversation, talking excessively, and disorganization, which present before the age of twelve years and last at least six months (Magnus et al., 2017). MT struggles with concentration, forgetfulness and does not listen to her mother. She is irritable and blows up frequently. She is also unable to sit still and fidgets a lot. The behavior occurs both at home and in school. The condition is ruled in based on the findings from the mental status examination indicating predominantly inattentive presentation with the interference of daily life activities at school and home.
2- Bipolar Disorder F31.9
Bipolar disorder is described as co-occurrence of manic or hypomanic episodes and depressive manifestations within the same mood episodes (Bartoli et al., 2020). The patient mood is characterized as high, irritable, or expansive with increased overall energy for at least one week. The patient should exhibit three or more of the following symptoms: grandiose thinking, diminished sleep, racing thoughts, increased goal-directed activities, and psychomotor agitation (Bartoli et al., 2020). Although MT presents symptoms of depresion, she does not endorse three of the core symptoms of bipolar disorder as mentioned above, ruling out the condition.
3- Generalized Anxiety Disorder (GAD) F41.9
GAD is a condition that causes excessive worry and anxiety for at least six months and can be found in multiple situations or settings (American Psychiatric Association, 2013). These symptoms must be accompanied by at least three of the following symptoms: restlessness, fatigue, difficulty concentrating, irritability, and muscle tension (Patriquin & Mathew, 2017). GAD is more common in females than in men, with approximately 55 to 60% of people with the disorder being female (American Psychiatric Association, 2013). MT is irritable and will sometimes punch the wall. She has trouble concentrating, has sleep problems, and is restless. Although MT presents some symptoms of GAD, this condition is ruled out due to the patient history of impulsity, fidgeting, and inattention.
Reflections:
Diagnozing this patient with ADHD was not obvious because she presented mixed symptoms of anxiety, hyperactivity, and depression. The patient could have had an anxiety disorder as her primary diagnosis, as she is be irritable, punches walls, and is isolated from others. Collateral information from the therapist, teachers, and other encounters with the patient could have strengthened the diagnosis impression. Because her mother didn’t want the patient to try medication, this patient was not on any medication trial. Research shows that combining psychotherapy and medications may be more effective than either treatment alone (Magnus et al., 2017). MT might benefit from low-dose Prozac or Zoloft to help her anxiety and irritable mood (Magnus et al., 2017). Legal and ethical considerations are essential to ensure that patients’ values, preferences and opinions are respected when treating mental disorders. It is important that the mother gives informed consent to allow the team to make the best decisions for the patient’s treatment (Magnus et al., 2017).
Case Formulation and Treatment Plan:
The patient appears to be suffering from anger issues, as evidenced by an irritable mood by punching the wall. Factors that predispose the patient to mental health disorders are the brother’s history of ADHD, the father history of bipolar, and the mother history of depression/anxiety. MT’s symptoms influence her daily life at home and in school. The mainstay treatment of ADHD entails pharmacological stimulants. However, MT mother declined pharmacological intervention. MT will begin psychotherapy, especially cognitive behavioral therapy (CBT). CBT teaches how to modify beliefs and behaviors that lead to negative thoughts and emotions (NYULangone Health, 2022). Through therapy, the patient would learn how to manage her anger and impulsivity. Since ADHD is associated with increased health risk such as drug use, binge eating, obesity, and unsafe sexual behaviors, It is paramount to monitor the patient for these conditions (Schoenfelder & Kollins, 2015).
One way to promote healthy behavior is by strengthening the patient’s social and environmental factors, such as resilience and academic engagement (Schoenfelder & Kollins, 2015). Programs that support parenting and family functioning have been shown to reduce the risk of substance use and obesity in ADHD patients (Schoenfelder & Kollins, 2015). Family Therapy assists siblings and parents in coping with difficulties in living with a child diagnosed with ADHD. Treatment with counseling enhances everyday functioning and avoids the need for more intensive treatment. The patient and her mother should be given the phone numbers for their local crisis hotline and suicide hotline, and instructions on how to get to the nearest local emergency facility in case of emergency.
Follow-Ups/ Referrals
• Follow-up in four weeks or PRN
• Provided the mother and patient the HelpLine 1-800-950-NAMI (National Alliance on Mental Illnesses) to get assistance in locating appropriate resources and finding support.
Discussion Questions:
1. What medications would you have started this patient on if the mother was amenable to pharmacological intervention?
2. What other assessment/screening tools would you have used to enhance the diagnostic impression?
3. What would you have done differently to promote effective treatment outcomes for this patient?
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, 5th edition: Dsm-5 (5th ed.). American Psychiatric Publishing.
https://doi.org/https://doiorg.ezp.waldenulibrary.org/10.1176/appi.books.9780890425596
Bartoli, F., Crocamo, C., & Carrà, G. (2020). Clinical correlates of DSM-5 mixed features in bipolar disorder: A meta-analysis. Journal of affective disorders, 276, 234-240. https://www.sciencedirect.com/science/article/pii/S0165032720324800
Cabral, M. D. I., Liu, S., & Soares, N. (2020). Attention-deficit/hyperactivity disorder: diagnostic criteria, epidemiology, risk factors and evaluation in youth. Translational Pediatrics, 9(Suppl 1), S104. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082246/
Magnus, W., Nazir, S., Anilkumar, A. C., & Shaban, K. (2017). Attention deficit hyperactivity disorder (ADHD). https://europepmc.org/article/med/28722868
NYULangone Health. (2022). Cognitive behavioral therapy for schizophrenia.
https://nyulangone.org/conditions/schizophrenia/treatments/cognitive-behavioral-therapyforschizophrenia#:~:text=Cognitive%20behavioral%20therapy%2C%20also%20known,be %20leading%20to%20negative%20emotions.
Patriquin, M. A., & Mathew, S. J. (2017). The neurobiological mechanisms of generalized anxiety disorder and chronic stress. Chronic Stress, 1, 2470547017703993. https://journals.sagepub.com/doi/abs/10.1177/2470547017703993
Schoenfelder, E. N., & Kollins, S. H. (2015). Topical review: Adhd and health-risk behaviors:
Toward prevention and health promotion. Journal of Pediatric Psychology, 41(7), 735–
740. https://doi.org/10.1093/jpepsy/jsv162
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