Help finish ADHD management plan and analysis
Chief complaint: Trouble concentrating
Subjective data:
History of Present Illness: 28-year-old male that reports struggling with inattention and hyperactivity since childhood. He has difficulty maintaining focus on tasks at work and is often forgetful with appointments and responsibilities. He mentions that he frequently feels restless and finds it hard to relax during the evening. These issues have worsened in recent years, particularly in his job as a real estate agent, where he often feels overwhelmed by multitasking and tight deadlines.
Demographic Data: Caucasian, working full-time, married.
Risk Factors: Mother with PMHx of ADHD.
Previous Medical, Surgical, and Psychiatric History: History of cholecystectomy in 2022.
Objective data:
Physical Exam Findings:
General- Patient cooperative but fidgety appearing.
HEENT- Head: Normocephalic, Eyes: Pupils equal round and reactive to light, Ears: No lesions and symmetric tympanic membrane pearly grey and intact, Nose: Nasal turbinate’s pink and moist, Throat: No exudate to pharynx and no dental caries noted.
Neurological- No numbness or weakness noted bilaterally, Cranial nerves intact. Denies headaches or blurred vision.
Cardiovascular- Normal s1 and s2 sounds noted. No cardiac murmur. Denies chest pain, palpitations, or shortness of breath.
Respiratory- No adventitious lung sounds noted. Denies cough or wheezing.
GI- Normoactive bowel sounds in all four quadrants. No masses palpated. Denies Nausea, vomiting, or diarrhea.
Psychiatric- Patient displays being fidgety during exam with frequent shifting in seat and tapping feet. Pt endorses trouble concentrating and staying still for long periods of time.
Mental Status Exam:
Appearance: Well-groomed and nourished.
Behavioral/Motor observation- Fidgety during time of exam with frequent shifting and tapping of feet.
Speech- Mild pressured speech occasionally interrupting.
Affect and Mood- Patient cooperative but anxious appearing.
Thought Process- Exhibits some disorganized and scattered thought process with frequent shifts in topics.
Cognition- Intact and well knowledgeable.
Recommended Diagnostic Tests:
Behavioral rating scale: Adult ADHD Self-Report scale which has been shown to have excellent psychometric properties which include questions on core symptoms and the frequency and impact of symptoms on daily functioning (Adamou, M., et al. 2024).
Use of Adult ADHD Investigator Symptom Rating Scale- This tool allows clinicians to guide questions to help in diagnosis and identifying patients with ADHD (Adamou, M., et al. 2024).
Screen for other neurodevelopmental disorders such as learning disabilities or intellectual disability (Adamou, M., et al. 2024).
Obtain developmental history, encourage life story timeline of how these behaviors have progressed thought life (Adamou, M., et al. 2024).
Reference:
Adamou, M., Arif, M., Asherson, P., Cubbin, S., Leaver, L., Sedgwick-Müller, J., Müller-Sedgwick, U., van Rensburg, K., & Kustow, J. (2024). The adult ADHD assessment quality assurance standard. Frontiers in psychiatry, 15, 1380410.
