By Ryan Raroque Case Study 46: Attention Deficit/Hyperactivity Disorder

By Ryan Raroque

Case Study 46: Attention Deficit/Hyperactivity Disorder

What is ADHD?

Psychological disorder that involves significant, age inappropriate issues with any or all of the following:

AttentionHyperactivityImpulsivity

Mother’s Chief Complaints-“I’m at the end of my rope and don’t know what to do anymore”


-He won’t behave in school or listen at home



-He’s always in motion and can’t sit still for five minutes




-He likes watching cartoons but gets bored in a matter of minutes




-He likes watching cartoons but gets bored in a matter of minutes

Mother’s Chief Complaints-His first grade teacher says he can’t sit still at schooland constantly squirms in his seat


-Sometimes gets up in the middle of class and roams around the room to look at different things



-Becomes problematic when he has to waitfor things that he wants




-Always grabs things away from other children





-Interrupts when others are speaking





-Interrupts when others are speaking

-Doesn’t wait for teacher to finish asking a question before beginning to answer

History of Present Illness

-6-year-old boy

-Mom says he’s shown hyperactive/inattentive behaviors for almost one year

-“Everything seems to be getting worse”

-Teachers complain that he doesn’t listen or follow instructions like other kids, gets easily bored during activities

-Has difficulty waiting his turn

-Can’t engage in playground games for any significant length of time

-Behavior has been so disruptive that no daycare centers will accept him

-Mom is a single parent and must work to support son and herself

Past Medical HistorySon was taken to pediatrician 4 months ago

for similar symptoms; Mother’s complaints were dismissed

Pregnancy and delivery were normalVaccinations up to dateNo prior surgeries, serious medical

problems, or established psychiatric illnesses

Family HistoryFather left the family before the boy was

bornBoth maternal grandfather and maternal

uncle have history of hyperactivity as children

Mother denies drug, tobacco, and alcohol abuse during pregnancy

Family HistoryFather left the family before the boy was

bornBoth maternal grandfather and maternal

uncle have history of hyperactivity as children

Mother denies drug, tobacco, and alcohol abuse during pregnancy

Miscellaneous Information

Occasional GI upset and colds

Review of Systems



Review of Systems

Medications

None



Review of Systems

Medications

None

Allergies

No Known Drug Allergies

Limited Physical Examination and Lab Tests

Hearing Vision Skin

Within Normal Limits


Warm and dry with no discoloration


Hearing Vision Skin




Head, Ears, Eyes, Nose, Throat

Neck/Lymph Nodes

Heart

PERRLA

Tympanic Membranes intact

Nose clear

Throat without erythema

Mucous Membranes normal

Neck supple without obvious nodal enlargement or thyromegaly

Regular Rate and Rhythm with no murmurs, rubs, or gallops


Hearing Vision Skin




Head, Ears, Eyes, Nose, Throat

Neck/Lymph Nodes

Heart

PERRLA

Tympanic Membranes intact

Nose clear

Throat without erythema

Mucous Membranes normal

Neck supple without obvious nodal enlargement or thyromegaly

Regular Rate and Rhythm with no murmurs, rubs, or gallops


Lungs Genitalia Abdomen

Clear, normal breath sounds

Normal external male genitalia with circumcised penis

Soft and non-tender with normal bowel sounds and no palpable viscera or masses






Musculoskeletal/Extremities

Neurological

No Cyanosis, Clubbing, or Edema

Range of motion intact

Good peripheral pulses bilaterally

Alert and Oriented

Cranial Nerves II-XII intact

Deep Tendon Reflexes 3+ throughout

Sensory and motor function intact and gait normal






Musculoskeletal/Extremities

Neurological

No Cyanosis, Clubbing, or Edema

Range of motion intact

Good peripheral pulses bilaterally

Alert and Oriented

Cranial Nerves II-XII intact

Deep Tendon Reflexes 3+ throughout

Sensory and motor function intact and gait normal

General AppearancePatient is healthy-appearing and well-nourished


He moves constantly, fidgeting with bothhis hands and feet



Gets easily distracted by minor noises



Gets easily distracted by minor noises

Repeatedly interruptshis mother and the pediatrician

Case Question 1Are any of the boy’s vital signs a major

cause for concern?


cause for concern?

BP 112/70

RR 15

HT 3’9

P 65

T 98.2 F

WT 50 lbs


cause for concern?

BP 112/70

RR 15

HT 3’9

P 65

T 98.2 F

WT 50 lbs

Age Heart Rate (beats/min) Blood Pressure (mm Hg)Respiratory Rate

(breaths/min)

3-6 yr 65-110 95-110/60-75 20-25

6-12 yr 60-95 100-120/60/75 14/22

12 > yr 55-85 110-135/65/85 12-18


cause for concern?

BP 112/70

RR 15

HT 3’9

P 65

T 98.2 F

WT 50 lbs


(breaths/min)

3-6 yr 65-110 95-110/60-75 20-25

6-12 yr 60-95 100-120/60/75 14-22

12 > yr 55-85 110-135/65/85 12-18


cause for concern?

BP 112/70

RR 15

HT 3’9

P 65

T 98.2 F

WT 50 lbs


(breaths/min)

3-6 yr 65-110 95-110/60-75 20-25

6-12 yr 60-95 100-120/60/75 14-22

12 > yr 55-85 110-135/65/85 12-18


cause for concern?

BP 112/70

RR 15

HT 3’9

P 65

T 98.2 F

WT 50 lbs


(breaths/min)

3-6 yr 65-110 95-110/60-75 20-25

6-12 yr 60-95 100-120/60/75 14-22

12 > yr 55-85 110-135/65/85 12-18

Case Question 2What is the patient’s single most critical

risk factor that is consistent with ADHD?





Additional Risk FactorsExposure to:

-Polychlorinated Biphenyls (PCBs)

-Lead

Case Question 3Can hyperthyroid disease be ruled out as a

cause of hyperactivity in this child?



Hb 15.1 g/dL

Plt 290,000/mm3

TSH 3.8 µU/mL

Ht 43%

BUN 11 mg/dL

T4’ total 6.8 µg/dL

WBC 7,253/mm3

Cr 0.7 mg/dL

Glu, fasting 75 mg/dL



Hb 15.1 g/dL

Plt 290,000/mm3

TSH 3.8 µU/mL

Ht 43%

BUN 11 mg/dL


WBC 7,253/mm3

Cr 0.7 mg/dL




Hb 15.1 g/dL

Plt 290,000/mm3

TSH 3.8 µU/mL

Ht 43%

BUN 11 mg/dL


WBC 7,253/mm3

Cr 0.7 mg/dL


Hb 11.5 -15.5 g/dL

Plt 150,000 – 450,000/mm3

TSH 0.32 – 5.0 µU/mL

Ht 34 – 40%

BUN 5-20 mg/dL

T4’ total 6.4 – 13.3 µg/dL

WBC 5 – 14.5/mm3

Cr 0.3-0.7 mg/dL

Glu, fasting 70 – 110 mg/dL



Hb 15.1 g/dL

Plt 290,000/mm3

TSH 3.8 µU/mL

Ht 43%

BUN 11 mg/dL


WBC 7,253/mm3

Cr 0.7 mg/dL


Hb 11.5 -15.5 g/dL

Plt 150,000 – 450,000/mm3

TSH 0.32 – 5.0 µU/mL

Ht 34 – 40%

BUN 5-20 mg/dL

T4’ total 6.4 – 13.3 µg/dL

WBC 5 – 14.5/mm3

Cr 0.3-0.7 mg/dL




Hb 15.1 g/dL

Plt 290,000/mm3

TSH 3.8 µU/mL

Ht 43%

BUN 11 mg/dL


WBC 7,253/mm3

Cr 0.7 mg/dL


Hb 11.5 -15.5 g/dL

Plt 150,000 – 450,000/mm3

TSH 0.32 – 5.0 µU/mL

Ht 34 – 40%

BUN 5-20 mg/dL

T4’ total 6.4 – 13.3 µg/dL

WBC 5 – 14.5/mm3

Cr 0.3-0.7 mg/dL




Hb 15.1 g/dL

Plt 290,000/mm3

TSH 3.8 µU/mL

Ht 43%

BUN 11 mg/dL


WBC 7,253/mm3

Cr 0.7 mg/dL

Glu, fasting 75 mg/dLNote that the physical examination

showed no obvious nodal enlargement or thyromegaly.

Case Question 4Is this patient’s CBC normal or abnormal?

Hb 15.1 g/dL

Plt 290,000/mm3

TSH 3.8 µU/mL

Ht 43%

BUN 11 mg/dL


WBC 7,253/mm3

Cr 0.7 mg/dL


Hb 11.5 -15.5 g/dL

Plt 150,000 – 450,000/mm3

TSH 0.32 – 5.0 µU/mL

Ht 35 – 46%

BUN 5-20 mg/dL

T4’ total 6.4 – 13.3 µg/dL

WBC 5k – 14.5k/mm3

Cr 0.3-0.7 mg/dL



Hb 15.1 g/dL

Plt 290,000/mm3

TSH 3.8 µU/mL

Ht 43%

BUN 11 mg/dL


WBC 7,253/mm3

Cr 0.7 mg/dL


Hb 11.5 -15.5 g/dL

Plt 150,000 – 450,000/mm3

TSH 0.32 – 5.0 µU/mL

Ht 35 – 46%

BUN 5-20 mg/dL

T4’ total 6.4 – 13.3 µg/dL

WBC 5k – 14.5k/mm3

Cr 0.3-0.7 mg/dL



Hb 15.1 g/dL

Plt 290,000/mm3

TSH 3.8 µU/mL

Ht 43%

BUN 11 mg/dL


WBC 7,253/mm3

Cr 0.7 mg/dL


Hb 11.5 -15.5 g/dL

Plt 150,000 – 450,000/mm3

TSH 0.32 – 5.0 µU/mL

Ht 35 – 46%

BUN 5-20 mg/dL

T4’ total 6.4 – 13.3 µg/dL

WBC 5k – 14.5k/mm3

Cr 0.3-0.7 mg/dL



Hb 15.1 g/dL

Plt 290,000/mm3

TSH 3.8 µU/mL

Ht 43%

BUN 11 mg/dL


WBC 7,253/mm3

Cr 0.7 mg/dL


Hb 11.5 -15.5 g/dL

Plt 150,000 – 450,000/mm3

TSH 0.32 – 5.0 µU/mL

Ht 35 – 46%

BUN 5-20 mg/dL

T4’ total 6.4 – 13.3 µg/dL

WBC 5k – 14.5k/mm3

Cr 0.3-0.7 mg/dL



Hb 15.1 g/dL

Plt 290,000/mm3

TSH 3.8 µU/mL

Ht 43%

BUN 11 mg/dL


WBC 7,253/mm3

Cr 0.7 mg/dL


Hb 11.5 -15.5 g/dL

Plt 150,000 – 450,000/mm3

TSH 0.32 – 5.0 µU/mL

Ht 35 – 46%

BUN 5-20 mg/dL

T4’ total 6.4 – 13.3 µg/dL

WBC 5k – 14.5k/mm3

Cr 0.3-0.7 mg/dL



Hb 15.1 g/dL

Plt 290,000/mm3

TSH 3.8 µU/mL

Ht 43%

BUN 11 mg/dL


WBC 7,253/mm3

Cr 0.7 mg/dL


Hb 11.5 -15.5 g/dL

Plt 150,000 – 450,000/mm3

TSH 0.32 – 5.0 µU/mL

Ht 35 – 46%

BUN 5-20 mg/dL

T4’ total 6.4 – 13.3 µg/dL

WBC 5k – 14.5k/mm3

Cr 0.3-0.7 mg/dL


Case Question 5What is the significance of this patient’s

BUN and Cr concentrations?

Hb 15.1 g/dL

Plt 290,000/mm3

TSH 3.8 µU/mL

Ht 43%

BUN 11 mg/dL


WBC 7,253/mm3

Cr 0.7 mg/dL


Hb 11.5 -15.5 g/dL

Plt 150,000 – 450,000/mm3

TSH 0.32 – 5.0 µU/mL

Ht 35 – 46%

BUN 5-20 mg/dL

T4’ total 6.4 – 13.3 µg/dL

WBC 5k – 14.5k/mm3

Cr 0.3-0.7 mg/dL




Hb 15.1 g/dL

Plt 290,000/mm3

TSH 3.8 µU/mL

Ht 43%

BUN 11 mg/dL


WBC 7,253/mm3

Cr 0.7 mg/dL


Hb 11.5 -15.5 g/dL

Plt 150,000 – 450,000/mm3

TSH 0.32 – 5.0 µU/mL

Ht 35 – 46%

BUN 5-20 mg/dL

T4’ total 6.4 – 13.3 µg/dL

WBC 5k – 14.5k/mm3

Cr 0.3-0.7 mg/dL




Hb 15.1 g/dL

Plt 290,000/mm3

TSH 3.8 µU/mL

Ht 43%

BUN 11 mg/dL


WBC 7,253/mm3

Cr 0.7 mg/dL

Glu, fasting 75 mg/dL-Within normal ranges

- Rules out the presence of kidney disease or malnutrition

Case Question 6Does this patient satisfy all of the criteria

that are required for a diagnosis of ADHD?


that are required for a diagnosis of ADHD? 1. Either criteria for inattention or criteria for

hyperactivity/impulsivity must be met2. Onset occurs no later than 7 years of age3. Symptoms must be present in two or more

settings 4. Behavior causes clinically significant distress

or impairment in social, academic, or occupational settings

5. Symptoms do not occur during the course of schizophrenia or another psychotic disorder

Criteria for InattentionFails to be closely attentive to details, makes careless

mistakes in schoolwork or other activitiesHas difficulty sustaining attention during tasks or

while at playDoes not seem to listen when spoken to directlyDoes not follow through with instructions and fails to

finish schoolwork, chores, or dutiesHas difficulty organizing tasks and activitiesAvoids/strongly dislikes tasks that require sustained

mental effortLoses items necessary to complete tasks or activitiesIs easily distracted by extraneous stimuliIs forgetful in daily activities

Criteria for Inattention









Criteria for Hyperactivity/Impulsivity

Fidgets with hands or feet or squirms in seatLeaves seat in classroom or in other situations in

which remaining seated is expectedRuns around or climbs excessively in situations in

which this behavior is inappropriateHas difficulty playing quietly or engaging in leisure

activitiesOften “on the go” or acts as if “driven by a motor” Talks excessivelyBlurts out answers to questions before questions

have been completedHas difficulty waiting turnsInterrupts or intrudes on others





































hyperactivity/impulsivity must be met 2. Onset occurs no later than 7 years of age 3. Symptoms must be present in two or more






hyperactivity/impulsivity must be met √2. Onset occurs no later than 7 years of age 3. Symptoms must be present in two or more






hyperactivity/impulsivity must be met √2. Onset occurs no later than 7 years of age √3. Symptoms must be present in two or more







settings √4. Behavior causes clinically significant distress







or impairment in social, academic, or occupational settings √







5. Symptoms do not occur during the course of schizophrenia or another psychotic disorder √






5. Symptoms do not occur during the course of schizophrenia or another psychotic disorder √

Case Question 7Is this patient predominantly hyperactive,

predominantly inattentive, does he show signs of combined inattention and hyperactivity, or are the minimal diagnostic criteria for ADHD lacking?

Case Question 7Is this patient predominantly hyperactive,

predominantly inattentive, does he show signs of combined inattention and hyperactivity, or are the minimal diagnostic criteria for ADHD lacking?

Predominantly Hyperactive

Case Question 8Which of the following is the most

appropriate therapy for this patient? Ritalin hydrochloride, 5 mg before breakfast

and lunchRitalin hydrochloride, 20 mg before each

mealCylert 37.5 mg as a single dose every

morning Adderall, 5 mg once daily + psychotherapyTofranil, 25 mg twice daily + psychotherapy


appropriate therapy for this patient? Ritalin hydrochloride

Prescribed for a stabilizing effect in children with ADHD

Should be initiated in small doses, starting with 5mg twice a day


appropriate therapy for this patient?

Cylert 37.5 mg as a single dose every morning


appropriate therapy for this patient? Cylert

Specifically indicated for treatment of ADHD


appropriate therapy for this patient? Cylert

Specifically indicated for treatment of ADHD

CAUTION: Associated with life-threatening hepatic failure



Adderall, 5 mg once daily + psychotherapy


appropriate therapy for this patient? Adderall

Specifically indicated for treatment of ADHD and Narcolepsy



Tofranil, 25 mg twice daily + psychotherapy


appropriate therapy for this patient? Tofranil

Used to treat depression


appropriate therapy for this patient? Ritalin hydrochloride, 5 mg before breakfast

and lunchRitalin hydrochloride, 20 mg before each

mealCylert 37.5 mg as a single dose every

morning Adderall, 5 mg once daily + psychotherapyTofranil, 25 mg twice daily + psychotherapy

Case Question 8Ritalin Adderall

Effects Increases amount of dopamine and norepinephrine between synapses in the brain.

Increases amount of dopamine and norepinephrine between synapses in the brain.

Potential Side Effects Nervousness, drowsiness, insomnia. Can cause psychosis with long-term use

Weight loss, insomnia, headaches, irritability, increased muscle tension, anxiety, increased heart rate, increased blood pressure, dry mouth, reduced efficacy over time.

Dependence Liability Lower compared to Adderall

High

Case Question 8

Case Question 8

Documents

By Ryan Raroque Case Study 46: Attention Deficit/Hyperactivity Disorder