Medicine And Health Case Study (ANSWERED)

QUESTION

Examine Case Study: A Young Caucasian Girl with ADHD. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

Introduction to the case (1 page)

Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.

Decision #1 (1 page)

Which decision did you select?
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #2 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #3 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Conclusion (1 page)

Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

Katie is an 8 year old Caucasian female who is brought to your office today by her mother & 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 this 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 interested in. The teacher opined that she lacks interest in school work and is easily distracted. Katie is also noted to start things but never finish them, and seldom follows through on instructions and fails to finish her school work.

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 of as more fun. “Sometimes” Katie reports “I will just 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, coherent, 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 mannerisms, 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 judgment appear age appropriate. Katie denies any suicidal or homicidal ideation.

Diagnosis: Attention deficit hyperactivity disorder, predominantly inattentive presentation

RESOURCES

Conners, C. K., Sitarenios, G., Parker, J. D. A., & Epstein, J. N. (1998). Revision and restandardization of the Conners’ Teacher Rating Scale (CTRS-R): Factors, structure, reliability, and criterion validity. Journal of Abnormal Child Psychology, 26, 279-291.

Decision Point One

Select what the PMHNP should do:

Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING

Decision point Two

Ritalin LA 20 mg

Decision point Three

Maintain Ritalin LA 20 mg and reevaluate.

ANSWER

Introduction

Attention deficit hyperactivity disorder (ADHD) typically results from a dysfunction of executive functions, mostly frontal lobe activity. Consequently, patients have difficulty paying attention and making decisions. Children with ADHD are typically labeled “trouble makers” due to their impulsive or hyperactive behavior. Magnus et al. (2020) reveal that this condition may persist into adulthood if left undiagnosed and untreated. This case study aims to prescribe medications for an eight-year-old Caucasian female diagnosed with Attention deficit hyperactivity disorder.

The patient’s subjective presentation includes lack of attention, forgetfulness, difficulty completing tasks, disinterest in school activities, and being easily distracted. The client, Katie, admits to being absent-minded in class and paying attention only to things that interest her. Her teacher indicated that Katie rarely completes tasks or follows through on instructions.

An objective assessment of the patient’s mental status showed that the patient is appropriately oriented, has a clear, coherent, and logical speech, and has no auditory or visual hallucinations, delusions, paranoia, or odd mannerisms such as tics or gestures. Her subjective mood is euthymic, and her attitude is bright. The mental health assessment also showed that the client’s attention and concentration are grossly intact, evidenced by the ability to count 100 backward by serial 2’s and 5’s. The client denies homicidal and suicidal ideation, and her judgment is age-appropriate.

Magnus et al. (2020) report that ADHD patients will present with inattentive symptoms such as rushing through tasks, failing to listen when talked to, avoiding tasks that require sustained mental effort, being forgetful, and difficulty finishing work. Based on Magnus et al.’s (2020) criteria, the behaviors exhibited by Katie result from her inability to stay attentive. Katie is diagnosed with ADHD, specifically inattentive disorder. The medication choices for this patient include Ritalin (Methylphenidate), Ritalin LA 20 mg, and maintaining the Ritalin LA 20 mg and reevaluation.

Decision 1

The client should start Ritalin (Methylphenidate) chewable tablets 10 mg orally in the morning. I chose this medication because drug studies recommend starting it at a low dose and adjusting it incrementally (Huss et al., 2017). Malaysian guidelines recommend starting at 5mg/day for eight-year-olds and 10 mg/day, >eight-year-olds. AAFP clinical guidelines also recommend dose titration (meaning starting the medication at a low dose) for ADHD medications, justifying my decision (Wolraich et al., 2019). Because 10mg/day is at the lower end of the dosage range, starting with it is the best choice.

I did not choose the other two medications because their doses are higher for a first-time patient. Katie has never been on ADHD treatment; a low dose of the medication will help her body adjust to the stimulant (Handelman & Sumiya, 2022). Clinical guidelines also recommend starting stimulant medications at low doses and changing the doses in small increments (Wolraich et al., 2019). Because Ritalin (Methylphenidate) is available in a smaller amount (10mg) than the other two, it is the best alternative for Katie.

I made this decision with the hope that it will help reduce Katie’s ADHD symptoms and improve her function and academic performance. A study by Handelman and Sumiya (2022) showed that 0.7 mg/kg (twice daily for six months) of Methylphenidate significantly improved students’ associative learning tasks and short-term memory. This study implies that Katie’s cognitive performance will improve. This cognitive improvement will be characterized by enhanced memory, attention, etc. Teachers and parents should note an improvement in Katie’s ability to concentrate at the end of the treatment.

Decision 2

The second decision is Ritalin LA 20 mg/day in one dose. I would select this option if the client’s symptoms failed to improve after the initial treatment. Studies have shown that higher doses of Ritalin are associated with symptom improvement (Wigal et al., 2017). Wigal and associates found that 20mg-60mg of a chewable methylphenidate extended-release tablet is safe, tolerable, and effective for children with ADHD. Therefore, increasing the dose from 10mg to 20 mg might help Katie if the initial treatment did not work.

I did not select the first option because continuing the 10mg/day regimen would be futile care. Medical futility is a treatment that cannot cure, improve, or restore a patient’s quality of life (Aghabarary & Dehghan Nayeri, 2016). It is futile for a practitioner to maintain the 10mg/day regimen even though it failed to improve Katie’s symptoms. I did not select the third option because one must start the Ritalin LA 20 mg before reevaluation.

Wigal et al.’s study (2017) demonstrated that 20mg-60mg of chewable Ritalin LA could yield significant improvements in attention two-eight hours after dose administration. Therefore, I hope Katie’s attention will significantly improve after increasing the medication dose.

Decision 3

Decision point three is to maintain Ritalin LA 20 mg and reevaluate. I selected this decision because high Ritalin doses can cause patients long-term adverse effects; thus, reevaluation and observation are essential. Handelman and Sumiya (2022) reveal that various ADHD guidelines recommend reevaluating treatment goals if practitioners decide to increase stimulant doses. Given that Ritalin is a stimulant, and the second decision entailed increasing Ritalin’s dose, a reevaluation must be part of the treatment regimen.

I did not select the first option because a lower dose of Ritalin failed to improve the patient’s second condition, forcing us to increase the dose to 20mg. As indicated above, when a stimulant’s dose is increased, practitioners must reevaluate to determine whether the medication is appropriate for the patient (Handelman & Sumiya, 2022). Therefore, I did not select the second option because it does not entail reevaluating, yet Ritalin is a stimulant.

I hope this decision will help me identify and manage any adverse effects Katie might be experiencing from the treatment. The AAFP indicates that the negative effects of Ritalin are dose-dependent and include dependency, sleep problems, anxiety, depression, headaches, abdominal discomfort, slow growth or height velocity, reduced appetite, and mood lability. Therefore, reevaluation will prompt me to assess the side effects Katie might be experiencing. After that, I will modify my treatment goal to meet Katie’s needs.

Conclusion

National guidelines recommend Methylphenidate as the first choice for ADHD treatment. Various drug studies have also demonstrated the medication’s safety, efficacy, and tolerability among children with ADHD, explaining why it’s recommended (Wigal et al., 2017). Ritalin (Methylphenidate) is a psychostimulant; therefore, its treatment success is dose-dependent. Clinical guidelines recommend starting at a low dose and then adjusting the stimulant incrementally until a positive and well-tolerated effect is achieved. These guidelines explain why I selected the Ritalin (Methylphenidate) chewable tablets 10 mg/day as the first option for Katie. The 10mg/day is at the lower end of the dosage range; hence, appropriate for Katie’s age (Huss et al., 2017). The dose was increased to 20mg/day because Katie’s condition may fail to improve after the initial treatment. (Huss et al., 2017) A higher dose is associated with improved symptoms, explaining why I selected the Ritalin LA 20mg/day (Wigal et al., 2017). Clinical guidelines recommend reevaluating treatment goals (the third option) (Handelman & Sumiya, 2022). The guidelines recommend reevaluation if practitioners decide to escalate stimulant doses, explaining why I selected the third option.

References

Aghabarary, M., & Dehghan Nayeri, N. (2016). Medical futility and its challenges: a review study. Journal of Medical Ethics and History of Medicine, 9, 11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5203684/

Handelman, K., & Sumiya, F. (2022). Tolerance to Stimulant Medication for Attention Deficit Hyperactivity Disorder: Literature Review and Case Report. Brain Sciences, 12(8), 959. https://doi.org/10.3390/brainsci12080959

Huss, M., Duhan, P., Gandhi, P., Chen, C.-W., Spannhuth, C., & Kumar, V. (2017). Methylphenidate dose optimization for ADHD treatment: review of safety, efficacy, and clinical necessity. Neuropsychiatric Disease and Treatment, Volume 13, 1741–1751. https://doi.org/10.2147/ndt.s130444

Wigal, S. B., Childress, A., Berry, S. A., Belden, H., Walters, F., Chappell, P., Sherman, N., Orazem, J., & Palumbo, D. (2017). Efficacy and Safety of a Chewable Methylphenidate Extended-Release Tablet in Children with Attention-Deficit/Hyperactivity Disorder. Journal of Child and Adolescent Psychopharmacology, 27(8), 690–699. https://doi.org/10.1089/cap.2016.0177

Wolraich, M. L., Hagan, J. F., Allan, C., Chan, E., Davison, D., Earls, M., Evans, S. W., Flinn, S. K., Froehlich, T., Frost, J., Holbrook, J. R., Lehmann, C. U., Lessin, H. R., Okechukwu, K., Pierce, K. L., Winner, J. D., & Zurhellen, W. (2019). Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics, 144(4), e20192528. https://doi.org/10.1542/peds.2019-2528