Subjective:
CC
(chief complaint): “I don’t need my focus pills anymoreâ€Â
HPI
: IT is a 16-year-old Asian American female who was brought in for medication stabilization. The patient is currently being treated with Straterra for ADD and Lamictal for epilepsy. Her current treatment is Lamictal 200 mg QD and Straterra 30 mg QD. The patient recently stopped taking her both of her medications because she felt that she didn’t need her “focus pills†anymore. She developed a seizure because she did not take her Lamictal for 3 days. The patient verbalized that she needed to speak with her psychiatrist and parents prior to changing her medications. She reported that she forgot and overlooked that she needed to continue treating her epilepsy with Lamictal. She has no history of inpatient psychiatric admission. She currently meets with a social worker twice a year, meets with her outpatient Psychiatrist every six months, and meets with her Neurologist once a year. Her parents are divorced, and she lives with her mother. She visits her father every other weekend. Her mother remarried and had a strong relationship with her mother, stepfather, and half-brother.
Substance Current Use: The patient denies any use of illicit drugs. She reports that she occasionally drinks caffeinated soda and ice coffee drinks.
Her father has history of illicit drug abuse and was treated for psychosis. Her mother has no history of illicit drug use and has no familial psychiatric history.
Medical History: The patient has history of epileptic seizures and asthma.
Current Medications
: Lamictal 200 mg QD and Straterra 30 mg
Allergies
:
Adderall, Ritalin, Shrimp.
Reproductive Hx
:
She denies use of birth control and has no previous pregnancies. Her last menstrual cycle was June 28, 2022.
Objective:
Diagnostic results
: NICHQ Vanderbilt Assessment Scale (ADHD Combined Inattention/Hyperactivity), EEG (diagnostic test for epilepsy), Blood pressure
Assessment:
Mental Status Examination:
The patient is a 16-year-old Filipino/Mexican American female who looks her age. She was cooperative during assessment. She was neatly groomed and dressed appropriately. She is able to ambulate independently, no alterations noted. Her speech is clear, coherent, concise, volume, and tone are appropriate to situation. Her thought process is goal directed and logical. At times she needs some encouragement by her mother. She denies any type hallucinations and no delusions are present. Her mood is euthymic, and affect is appropriate. She denies any homicidal ideations and suicide ideations. She is alert and oriented. Her recent and remote memory are intact. She has a mildly poor concentration, and her insight is good.
Diagnostic Impression:
Attention Deficit Hyperactivity Disorder- The patient exhibit symptoms of inattention by failing to pay close attention to details and tasks, needed multiple prompting with directions. She also has difficulty staying on task and completing schoolwork. She has periods of daydreaming and becomes easily distracted (American Psychiatric Association, 2022). She has difficulty organizing her task and mother reports that she abandons her tasks most of the time. She loses things most of the time and is forgetful. During assessment, patient is observed staring while being spoken to and needs mother to prompt patient to answer questions. She also has forgotten to take her medications resulting in having a seizure episode.
Generalized Anxiety Disorder- The patient has exhibited and reported symptoms of difficulty with concentration, irritability, becoming fatigued easily, reports difficulty staying asleep and falling asleep, and excessive worry with certain issues (American Psychiatric Association, 2022).
Oppositional Defiant Disorder- The patient has periods of irritable mood, has been argumentative and defiant, and has been aggressive to one peer in the past (American Psychiatric Association, 2022). She loses her temper at times and becomes easily annoyed (American Psychiatric Association, 2022). She at time argues with her parents and refuses to comply with parent requests (American Psychiatric Association, 2022). Although the patient does exhibit some symptoms of Oppositional Defiant Disorder, it is not witnessed consistently in a period of 6 months.
Reflections:
The Psychiatrist diagnosed the 16-year-old patient with attention deficit disorder, which I totally agree with. According to the DSM-V, the patient exhibits six of the sypmtoms described. She has difficulty with concentration, staying on task, inability to follow directions, difficulty staying organized, avoids engaging in activities that she finds overwhelming, becomes easily distracted, and is very forgetful. She is being treated with Straterra 30 mg QD which seems to be effective. She was originally treated with Adderall and Ritalin, but unfortunately, she developed a seizure on that treatment. She is also being treated with Lamictal 200 mg QD for her epilepsy. Her second-grade teacher requested that she gets evaluated for ADHD due to her behavior and performance in class. In the year 2016, 6.1 million children were diagnosed with ADHD and almost 62% of those children are taking medications and being treated (Danielson et al.,2018). In order to diagnose a child with ADHD, the parent and teacher must fill out a NICHQ assessment scale (NICHQ.org). Patients with ADHD are treated with stimulant and non-stimulant medications, but patients that are treated with stimulant medications (Methylphenidate or Amphetamines) can affect their cardiac health Hennissen et al., 2017). Monitoring the patient blood pressure needs to be monitored.
The patient’s mother approved my involvement in the patient’s case, and I was able to continue patient’s confidentiality due this assessment. The patient’s father has history of polysubstance abuse and ADHD, I was able to discuss the importance of refusing illicit drug use and to not drink alcohol due to the medications she is being treated with. The patient’s parents are divorced and she reported that her father does not agree with her being treated with Straterra and Lamictal. I explained to the patient the importance of why she is on her medications and if she wanted to change her medications she needed to discuss with her psychiatrist on the changes. I also discussed the importance of taking her medications as directed so she will not have a seizure in the future.
Case Formulation and Treatment Plan:
The diagnostic test needed to diagnose the patient’s ADHD is the NICHQ (nichq.org). She will also need blood pressure monitoring to cardiac effects on her medications (Hennissen et al., 2017). She will also need yearly EEG’s to monitor the effectiveness of her treatment. The patient will need a referral for her primary physician and a referral to a neurologist to monitor her seizures and treatment. She can benefit with Cognitive Behavior Therapy to help her identify her emotions and symptoms and help manage her anxiety and oppositional behaviors. She should continue to have a follow-up appointment every 6 months, she has been stable with her treatment.
Risk and benefits of her medication has been discussed with the patient. The patient is requesting if she can try not taking her Straterra. The psychiatrist discussed with the patient that it is okay to stop during Summer break but will reassessed after 4 weeks of school. She is aware that she needs to be monitored if she wants any medication adjustment and is not able to stop her medications abruptly due to side effects. The patient is aware that she will inform her parents and her doctor if she is experiencing any side effects. The patient was educated on safe sex practices and given information on contraception. She requested a referral to an OB-GYN.
The patient is made aware that she should not mixed her medication with any OTC drugs, herbal, alcohol, and illegal drugs. She was encouraged to maintain abstinence. She is aware how drugs and alcohol can affect her overall health.
Lamictal 200 mg QD for seizure
Patient will discontinue Straterra and will reassessed how ability to perform once school starts.
She will continue to meet with her Case Manager every 6 months.
Client has emergency numbers to 911 (emergency services). Crisis line 714-639-4673, she is instructed to go the ER or call 911 if she is having suicidal or homicidal thoughts.
The time allotted for questions and answers were 30 minutes. The patient was provided with supportive listening, she verbalized that she understood the content. She agrees with the plan and the psychiatrist honored patient’s wish to ceased treatment with Straterra.
She will return to the clinic in September when school starts. Mom will call receptionist once school starts to make an appointment.
