Student Name: Solange Wilson

Patient initials: Z.C

D.OB: 08/24/2015

Date of Service: 03/30/23

Source of information: Patient and Patient’s Mother

Subjective: CC “she has problems following instructions”

HPI: Z.C is a 7 Y old 2nd grader Caucasian Female with history of ADHD and ADD that was

diagnosed in 2019 and is currently managed by her pediatrician. She is here today accompanied

by her mother to establish care with this office. Z.C currently takes Methypheninidate ER 36mg

QD in the morning (was increased from 18mg yesterday 03/29/23), Amphetamine salts 20mg

QD at 2pm, Clonidine 0.3mg HS and Melatonin 6mg HS. Mother is reporting that she is having

problems with her following instructions and getting ready for school on time. Mother also

reports that the school calls her multiple times with complains about her not paying attention,

constantly doing opposite of what is instructed and not completing work. Mother states that she

displays impulsive behaviors at home when she things are not going her way. As per mother “she

gets to school late almost every day because she wants to do her own thing in the mornings”.

Patient is reports difficulty falling and staying asleep. As per patient “I stay on the bed a long

time before I start sleeping and then I wake up again”. Mother states that she gets between 4-6

hours of sleep "maybe". Mother recall that “she is awake since 2am this morning and it is now

10am”. Patient denies having any dreams or nightmares. Mother states her appetite fluctuates

"sometimes she eats and other times she don't. Patient states “I eat mostly eat sandwiches and

snacks”. Mother denies any weight loss. Patient denies SI/HI/AH/VH and delusion at this time. 
Objective MSE

The patient is appropriately dressed for the weather, well-groomed. She has uniformed skin color

and appear stated age. Z.C is alert oriented to person, place, time and situation. Patient’s mother

was the primary source of information although patient was partially reliable . She was able to

recall the number of medications she takes, reason for taking them, time she should take them

and what happens if she does not take them. She is calm and cooperative. She spent most of the

visit using cellphone but makes minimal eye contact when prompted to do so. Patient

participates appropriately throughout this visit. Her speech is organized and regular in rate and

tone with appropriate responses. Thoughts process is appropriate for her age. Her mood is

euthymia and affect congruent. She demonstrates good judgement and insight beyond 2 nd grader

level. There is no evidence of any delusional thinking, perceptual disturbances, suicidal or

homicidal ideation and she denies same.

Assessment

PHQ9-0

GAD7-2

Vitals: BP: 110/69 HR: 71, temp: 97.6, RR: 18

Current Medications

Methylphenidate ER 36mg QD in the morning (was increased from 18mg yesterday 03/29/23),

Amphetamine salts 20mg QD at 2pm,

Clonidine 0.3mg HS

Melatonin 6mg HS
Past Medications

Mother states that the pediatrician has tried multiple medications but they did not work. These

medications include:

Vyvanse- “did not work she was still doing the same things”

Focalin- did not work 

Adderall –“worked for a short period then stopped working”

Eveko- “did not work”

Diagnosis: Attention-deficit hyperactivity disorder, unspecified type - F90.9, Primary diagnosis

Plan:

-No refills needed for stimulants at this time. 

-Since Methylphenidate was just increased yesterday (3/29/23) to 36mg we will continue to

monitor at this time. 

-Increase Melatonin to 10mg HS

-Discontinue clonidine 0.3mg- Mother advised to stop using clonidine, she verbalized

understanding

-Start guanfacine ER 2mg HS

-Placed on therapy waitlist- resources given on list of therapies that mother can seek at this time.

-Future plans include switching from stimulants to non-stimulants when patient is on a break,

possibly this summer. 

-Provide letter for School to indicate the patient requires special accommodation

-RTC- 2 weeks
Neurobiology

Attention-deficit/hyperactivity disorder (ADHD) is a mental health disorder that includes

a combination of persistent problems, such as difficulty paying attention, hyperactivity and

impulsive behavior (American Psychiatric Association, 2023). It is often first identified in school-

aged children when it leads to disruption in the classroom or problems with schoolwork. A

diagnosis is based on the presence of persistent symptoms that have occurred over a period of

time and are noticeable over the past six months reuptake inhibitor, atomoxetine, are the other

FDA-approved options for treating ADHD (American Psychiatric Association, 2023)

According to current guidelines, psychostimulants (amphetamines and methylphenidate)

are first-line pharmacological treatments for the management of ADHD. In preschool-aged

patients with ADHD, amphetamines are the only FDA-approved medication, although guidelines

suggest that methylphenidate rather than amphetamines may be helpful if behavioral

interventions prove insufficient. Alpha agonists (clonidine and guanfacine) and the selective

norepinephrine reuptake inhibitor, atomoxetine, are the other FDA-approved options for treating

ADHD (American Psychiatric Association, 2023)

I agree with the preceptor’s plan for this patient. Adding guanfacine HS may help the patient to

sleep as sedation is one of the most common side effects (Stahl, 2021). In addition, individuals

are more prone to developing addictive behaviors when on a stimulant (Stahl, 2021), so I also

agree with transitioning patient at a later date if appropriate. I also agree closely in the plan to

monitor recent increase in methylphenidate dosage.

 References
American Psychiatric Association. (2022). What is ADHD? Retrieved from:
https://www.psychiatry.org/patients-families/adhd/what-is-adhd

Stahl, S. (2021). Stahl’s essential psychopharmacology. (7th ed.). Cambridge