TASK:
19 year old male presented to GP surgery with some concerns.
Talk to the patient and address his concerns.
PT INFO:
[Body language : shaking legs and looking around everywhere]
Scenario A: Tutor asked you to see doctor due to concerns about your concentration
Scenario B: You approached the University nurse yourself because you had trouble concentrating.
Scenario C: You went directly to the doctor.
You are aware that you lack concentration.
One time you forgot a pan in the oven.
Struggling at University with concentration.
Likes maths but not other theoretical subjects that require sustained mental effort.
First noticed these problems in primary school.
Fit and well and not on any medications.
No problems making friends.
APPROACH:
GRIPS – How can I help?
Explore Inattention:
- Can you clarify what you mean by problems concentrating / inattention.
- Since when
- Specific situations (e.g. school)
- Any comments (by who)
ADHD assessment (NICE CKS)
Inattention symptoms:
- Failing to give close attention to detail or making careless mistakes in schoolwork, work, or other activities.
- Difficulty in maintaining concentration when performing tasks or play activities.
- Appearing not to listen to what is being said, as if the mind is elsewhere, without any obvious distraction.
- Failing to follow through on instructions or finish a task (not because of oppositional behaviour or failure to understand).
- Difficulty in organizing tasks and activities.
- Reluctance, dislike, or avoidance of tasks that require sustained mental effort.
- Losing items necessary for tasks or activities such as pencils, mobile phones, or wallets.
- Easy distraction by extraneous stimuli.
- Forgetfulness with regards to daily activities.
Hyperactivity-impulsivity symptoms:
- Fidgeting with or tapping hands or feet, or squirming when seated.
- Leaving the seat where remaining seated is expected, such as in a classroom.
- Running about or climbing in situations where inappropriate. In adolescents or adults this may be limited to a feeling of restlessness.
- An inability to play or engage in leisure activities quietly.
- Being ‘on the go’ or acting as if ‘driven by a motor’. Others may experience the person to be restless or difficult to keep up with.
- Talking excessively.
- Blurting out an answer before a question has been completed.
- Difficulty waiting his or her turn.
- Interrupting or intruding on others.
Suspect attention deficit hyperactivity disorder (ADHD) if:
- 5 or more inattention symptoms (6 or more in children)
- And/or 5 or more hyperactivity-impulsivity symptoms (6 or more in children)
- Started before 12 years of age.
- Occurred in two or more settings such as at home and school.
- Been present for at least 6 months.
- Clearly interfered with, or reduced the quality of social, academic or occupational functioning.
• Not occurred exclusively during the course of a psychotic disorder and are not better explained by another disorder such as oppositional defiant disorder or conduct disorder.
DDx:
- Anxiety disorder (worries)
- Depression (mood)
- Autism (can’t talk, can’t make friends, repetitive behaviours)
PMAFTOSA
Psychosocial (Effects) – Important:
- Home and ADLs (activities of daily living)
- University
- Relationships (arguments, frustration by others)
- Hobbies
PROVISIONAL DIAGNOSIS
Attention deficit hyperactivity syndrome (ADHD)
- Offer explanation – is that something you’ve heard of? Would you like me to explain that further?
It’s a bit of a fancy term but simply means problems with attention and more active than normal.
MANAGEMENT
Decision → Refer to Mental Health Specialist to confirm diagnosis.
What specialist will do:
- Assessment to confirm diagnosis
- Support with ADLs: Group based support programmes to learn about conditions and strategies to help you, can attend with parents.
- Support with Education: Contact University to make sure they understand you have this condition so that they can give you the support you need.
- Methylphenidate (Ritalin)
Reference: PLAB 2 Cases by Dr Hashim