Is there any additional information you would like or need to know about this client?

Module/Quiz #6 – ADHD

This client is a 21 year old male who has been
admitted to the in-patient psychiatric unit for suicidal ideation. You are the
covering PMHNP and are scheduled to see this client this morning for an initial
psychiatric evaluation.
History of Presenting Illness (HPI):
According to
the patient information form, the client had disclosed suicidal ideation to his
friend after consuming a considerable amount of alcohol at his 21st
birthday party. The client apparently was arrested by the campus police for
engaging in an altercation on campus while under the influence of alcohol at
this same party. The client reports that his mid-term grades are failing and he
fears he will be expelled from college due to his failing grades, and these
recent events that have occurred on campus.
The client reports his mood is irritable, sleep is
problematic as he has difficulty getting to sleep and staying asleep. He
reports early waking and not feeling rested. He reports his appetite improves
after he smokes marijuana and smokes this on a daily basis. He reports having
“a short fuse”, and his anger often gets him in trouble. He reports sometimes
acting impulsively which also tends to get him in trouble. The client reports
his concentration is not good and he is easily distracted. He reports handing in
course work late because of this, and feels this has contributed to his failing
grades.
Past Psychiatric History:
No previous psychiatric hospitalization. Diagnosed
with ADHD age 10, had been on Ritalin in the past. Client reports that he
stopped that medication when he started high school because he didn’t like
feeling “different and didn’t want to be labeled.” The client reports he was diagnosed with depression
around age 19 after his family had brought him to a Psychologist due to his
sometimes violent and angry outburst at home. The client reports he was treated
with sertraline which seemed to help with his angry outbursts, but made him
feel, “blah all the time.” The client reports he discontinued this medication
and did not go back for a follow-up visit as he did not want to be on another
medication.
The client recalls that as a child he was not
disruptive in class but had difficulty handing in assignments on time due to
“procrastinating and daydreaming”. The
client reports that he would often tell his mother that he had finished his
homework when he actually had not. The client reports he was inattentive and
impulsive, and often times the teacher would have him sit at the front of the
class room to help him pay attention.

Past
Medical History:
Seizure
disorder age 18 after head injury secondary to MVA (currently stable on
medication)

Medications:
Levetiracetam
– Keppra 500mg by mouth twice a day.

Family
History (FH):
Mother
living- no health issues, works as advance practice nurse at a medical center.
Father-
living, no health issues, retired middle school principal.
Two
brothers, both living and well, older brother finishing a law degree at Yale, younger
brother has ADHD and currently on medication for this.

Developmental:
Born
on time, C-section, reached developmental milestones on time. No history of
exposure to substances in utero. Mother did not smoke during pregnancy and had
adequate prenatal care.
No
history of abuse or trauma.

Social
History (SH):
History
of tobacco use starting age 15, currently uses Vape
Moved
back home recently with his parents after getting in trouble at college but not
sure if he will be able to stay there as he recently destroyed some household
property during one of his angry outbursts.
Employed
as a waiter part-time at a local restaurant (duration 9 months)

Substance
Use/Abuse History:
Marijuana
use daily
Have
experimented with various substances to include alcohol since age 15 (denies IV
drug use or snorting drugs)

Medications:
Levetiracetam,
Keppra 500mg by mouth twice a day.

Physical
and Lab Findings:
Ht.
6’, Wt. 165lbs, T
98.6, P 80, R 16.

Lab
values:
Hepatic:
Total Bilirubin 0.5, Alkaline Phos.
75, Alanine Aminotransferase 23,
Aspartate Aminotransferase 18.
Hemogram: Hemoglobin 15.9, Hematocrit 46.5, Platelet count 214.
Thyroid: TSH 0.86
Urine
Drug Screen: Positive for Cannabinoids-urine

QUESTIONS:

1. Is
there any additional information you would like or need to know about this
client?

2. After
reviewing the case study, are there any additional labs that you would order
and why?

3. If
labs return normal, and there is no medical reason for this client’s symptoms,
what will be your primary mental health diagnosis? Will there be a secondary
mental health diagnosis? (Give
supporting rationale for client’s symptomology using DSM-5 criteria)

4. Is
there any medication the client is currently taking that could be causing or
exacerbating his mood or behavior?

5. Will
you treat with a medication? (yes/no,
why)

6. What
medication/class would you prescribe for this client? (If more than one medication, please answer
a-d for each med)

a. Initial
dose:
b. Titration
Plan:
c. Goal
Dose Range:
d. Max
Dose:

7. Provide
rationale for the medication you selected above other medication options.

8. What
is your client education regarding the timing and onset of effect (how long
with the client need to wait to see a positive effect from the medication)?

9. How
will the therapeutic response be evaluated?

10. What
are the potential side effects from this medication? (name two common and one
severe side effect)

11. Are
there any contraindications between what you have prescribed for your client
and the medication/s the client is already taking?

12. Are
there any lab values that need to be ordered for a client taking this
medication, and how frequently?

13. Will
you order any additional therapies for this client? (what and why)

14. When
will you schedule your client back for follow up?

Please don’t forget to cite all your sources. Thank you.

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