Chief Complaint “My son has trouble focusing and sitting still..
Chief Complaint
“My son has trouble focusing and sitting still while completing his afternoon homework.”
HPI
David Handlon is a 10-year-old boy who returns for a routine visit to his psychiatrist with his mother. He was diagnosed 2 years ago with ADHD and is currently being treated with Adderall XR 20 mg every morning. His mother states that during the last parent-teacher meeting, his teacher indicated that David’s behavior is well controlled during the day. Despite David’s good behavior during the day, his mother reports difficulty getting David to complete any afternoon tasks or assignments after school. David’s rules include no playtime activities until he has completed his afternoon homework assignments. Instead of focusing on homework, David insists on playing Guitar Hero® in his room, and he sometimes carelessly throws his guitar. David has also exhibited impulsive and reckless behavior when interacting with his younger 8-year-old brother. Initially David’s mother thought the medication was working. However, within the past year, David’s afternoon antics have progressively gotten worse. Mrs Handlon is afraid that uncontrolled afternoon antics will have serious repercussions on David’s daytime behavior and grades. She questions, “What are my options?”
PMH
Asthma × 3 years
ADHD × 2 years
Tonsillectomy (1 year ago)
Broken wrist at age 8 (fell from tree)
Vaccinations up to date
FH
Both father and uncle have a history of hyperactivity and are currently receiving treatment as adults.
SH
Lives with both parents and younger brother in the suburbs
Meds
Adderall XR 20 mg daily (given every morning at 7:00 AM)
Albuterol inhaler two puffs Q 4-6 H PRN shortness of breath
Montelukast 5 mg PO daily
All
NKDA
ROS
Physical assessment was difficult to assess for David as he could not sit still for more than 30 seconds and was jumping off of the exam table. Asthma symptoms appear controlled with PRN inhaler use at bedtime only and daily montelukast.
PEGen
Well-nourished, healthy-appearing male child, normal physical development
VS
BP 110/72 mm Hg, P 82 bpm, RR 25, T 37.5°C; Wt 50 kg, Ht 5′2″
Skin
No signs of rash, skin irritation, or bruising noted. Scar noticed on left wrist from where he fell from tree. Minor cuts on knees from frequent falls on school playground.
HEENT
Unable to assess
Neck/Lymph Nodes
Unable to assess
Lungs/Thorax
No rales, rhonchi, or wheezing
CV
RRR
Abd
Deferred
Genit/Rect
Deferred
MS/Ext
Unable to assess
Neuro
A&O × 3; no underlying tics noted
Labs
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| Na 138 mEq/L K 3.8 mEq/L Cl 106 mEq/L CO2 23 mEq/L BUN 18 mg/dL SCr 0.8 mg/dL Glu 110 mg/dL | Hgb 14 g/dL Hct 44.5% RBC 4.6 × 106/mm3 Plt 278 × 103/mm3 MCV 85 μm3 MCHC 33 g/dL
| WBC 9 × 103/mm3 Neutros 66% Bands 2% Eos 3% Lymphs 24% Monos 5%
| Mag 1.8 mg/dL Serum iron 95 mcg/dL TSH 3.6 mIU/L
|
ECG
NSR; changes not clinically significant
Assessment
ADHD
Mild-persistent asthma, well controlled with PRN albuterol and daily montelukast
1. What should the goals of pharmacotherapy be in this case?
2. What nondrug therapies might be beneficial for those diagnosed with ADHD?
3. What feasible pharmacotherapeutic alternatives are available for the treatment of ADHD?
4. What might an individualized, patient-centered, team-based care plan look like for this type of patient? Including specific drugs, dosage forms, doses, schedules, and durations of therapy.
5. What alternatives would be appropriate if the initial care plan fails or cannot be used?
6. What information should be provided to the patient to enhance adherence, ensure successful therapy, and minimize adverse effects?
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