bobbie-vault/Library/2026-01-07 AI Summary, ADHD Titration Appointment.md

---
created: 2026-01-07T19:15:54
category:
  - "[[Library]]"
title: "AI Summary, Medical Review: ADHD Titration Appointment"
source: "[[Recording 20260107161403.m4a]]"
author:
  - "[[AI Gemini|Gemini]]"
published: 2026-01-07
topic:
---
[[Recording 20260107161403.m4a]]

## AI Summary

## Medical Review: ADHD Titration Appointment

### Patient & Attendees
- **Patient:** [[Bobbie Nathan Hodgetts|Bobbie]]
- **Primary Practitioner:** [[Dr Marie Cawley NSCHT Psychiatrist|Dr Marie Cawley]]
- **Nurse Practitioner:** [[Laura NSCHT 2026-01-07|Laura]]

### Medication Overview
- **Current Prescription:** [[Elvanse|Elvanse]] 30mg (Switched from [[Concerta|Concerta]] 54mg in November).
- **Patient Feedback:** Bobbie reports that the current 30mg dose is significantly less effective than Concerta, resulting in a noticeable dip in concentration.
- **Goal:** To find a therapeutic dose of Elvanse that matches the efficacy of previous medications ([[Medikinet|Medikinet]]/Concerta) but with fewer side effects (e.g., lower heart rate compared to Medikinet).

### Clinical Observations
- **Vitals (Self-Reported):**
    - **Blood Pressure:** 119/78 (Stable).
    - **Pulse:** 56 bpm.
    - **Weight:** 86 kg (Stable).
- **Side Effects on Elvanse 30mg:**
    - **Sleep:** No issues reported.
    - **Appetite:** Slight decrease, but still eating adequately.
    - **Mood/Mental Health:** Stable and fine.
- **Medical History:** History of paroxysmal atrial fibrillation; prescribed Bisoprolol but has never required it.

### Revised Treatment Plan
- **Dose Adjustment:** Increase Elvanse to **50mg daily**. 
    - *Note:* While 40mg is the standard next step, S1 agreed to a larger jump to 50mg due to the patient’s size and his prior tolerance for higher stimulant doses.
- **Risk Management:**
    - Patient warned of potential nausea, headaches, or vomiting due to the 20mg increase.
    - Backup prescription for 40mg will be provided if the 50mg dose is poorly tolerated.
- **Prescription Logistics:**
    - To be collected from [[Bennet Centre|Bennett Centre]] on Monday after 1:00 PM.
    - Patient to continue current 30mg dose until the new supply is collected.
- **Admin Advice:** Weekend breaks from medication are permitted (max 4 days off) to allow for alcohol consumption.
- **Follow-up:** Review in 4 weeks, potentially with Nurse Practitioner Laura.

***
### Transcription

**00:00 Marie:** Hello.

**00:03 Bobbie:** Hello.

**00:05 Marie:** Hi, how you doing?

**00:08 Bobbie:** I'm good, thank you.

**00:10 Marie:** Um, so Bobbie, just before we start, um, I hope it's okay, we've got nurse practitioner Laura who is just going to join, um, she's just about to join. Um, so she's taken over from the role of our previous nurse practitioner, [[Claire Budding|Claire]], and it's likely that you're going to be seen her in the future, so I just wanted to introduce you guys. So Laura, Bobbie; Bobbie, Laura.

**00:34 Bobbie:** Yes, sure.

**00:35 Laura:** Hi.

**00:36 Bobbie:** Hi.

**00:38 Laura:** Hi Bobbie. Nice to meet you.

**00:41 Bobbie:** And you.

**00:42 Marie:** Um, so we, we're doing your titration appointment again today and um, you last saw me was in November, um, so let's have a look what the plan was last time. Um, so you'd asked to stop the Concerta and you wanted to go over to Elvanse. So what we did Laura, Bobbie was on a dose of 54 milligrams of Concerta. Um, when we're switching over to Elvanse, you, you don't just do a, do a straight swap just because um, the, the side effect profile can be a bit more powerful with Elvanse. Concerta's quite gentle with side effects usually. So what we, what we did we went to a dose of 30 milligrams, um, which is like a, you know, a starting dose for, for somebody of Bobbie's weight and height. Um, how have you been finding the medication, Bobbie?

**01:43 Bobbie:** Um, I haven't really noticed it to be fair, yeah. Um, I don't think it's enough. I don't notice it anywhere near as much as the Concerta.

**02:00 Marie:** Yeah, which, you know, it would be because we've started you on like a basic dose and an equivalent to Concerta is 50 basically, um, in...

**02:11 Bobbie:** Right.

**02:12 Marie:** Are you still taking your Bisoprolol at the moment?

**02:14 Bobbie:** Sorry, say that again? The sound's gone a little bit.

**02:17 Marie:** Sorry, are you still taking your Bisoprolol at the moment?

**02:21 Bobbie:** Uh, I've never actually taken it. I was prescribed it years ago as a pill-in-pocket kind of thing but yeah, I've never...

**02:29 Marie:** You never actually take...

**02:30 Bobbie:** I've never had to take one, no.

**02:31 Marie:** Um, so that was prescribed initially for atrial fibrillation, is that right?

**02:37 Bobbie:** Yeah, paroxysmal or whatever it is, yeah.

**02:40 Marie:** The paroxysmal one, yeah, that's the one, yeah. Yeah. Okay, no problem. Um, so we were changing Concerta for Elvanse. So you've not found it to be as effective as the Concerta 54 milligrams. Have you noticed, say, like a dip in your concentration then?

**03:13 Bobbie:** Yeah, yeah, definitely.

**03:16 Marie:** Okay.

**03:22 Marie:** So the reason for, for changing, um, because originally you'd been on Medikinet but you were having some side effects with like a high heart rate at rest, so that's the original reason why you switched to Concerta. Um, but what Bobbie was finding was that he was more motivated on the Medikinet than he was on the Concerta, um, and you were starting to struggle to keep up with assignments, weren't you?

**03:57 Bobbie:** Yeah, that's right.

**03:58 Marie:** So the idea was we change to a different stimulant, build you up to a therapeutic dose in the hope that you'll get better symptom control than you did with the Concerta and, you know, as I said previously, the Medikinet, um, particularly with side effects, it can have quite a few in comparison to the Concerta. The Concerta seems to be a bit more gentle but in addition, you don't end up getting as good, um, control of the ADHD symptoms in certain patients and I think that's what you were experiencing with it, Bobbie.

**04:35 Bobbie:** Yeah.

**04:36 Marie:** Um, okay. So um, how has your sleep been on the Elvanse?

**04:42 Bobbie:** Uh, fine. Yeah, no problems there.

**04:46 Marie:** Okay.

**04:47 Bobbie:** As far as side effects go, there hasn't really been any at all.

**04:53 Marie:** That, that's good to know. So not had any side effects. And how's your appetite?

**05:03 Bobbie:** Um, it has affected my appetite a little. Um, yeah, but I still eat enough too much to be fair, so...

**05:11 Marie:** The appetite's dipped a little but you're still eating fine?

**05:14 Bobbie:** Yeah, yeah.

**05:31 Marie:** Have you, have you been diagnosed with any other medical problems at all since the last time we spoke?

**05:38 Bobbie:** No.

**05:39 Marie:** No. Okay. Um, so Bobbie, I can't remember, last time, did we take the observations during the, during the call or do you normally go somewhere else to get your blood pressure done?

**05:54 Bobbie:** I've, I've, I just gave you the, because I normally do them on a kind of regular basis myself anyway because I've got a blood pressure monitor, so I just gave you the last readings that I took.

**06:04 Marie:** Have you, have you got some up-to-date ones?

**06:06 Bobbie:** I did one yesterday in anticipation, yeah. Uh, where are we? That's the sixth. Yeah, so yesterday morning it was 119 over 78.

**06:22 Marie:** Yeah, so that, that's really similar to the last reading, very stable. And what was your pulse?

**06:28 Bobbie:** 56.

**06:30 Marie:** Okay. And do you know what your weight is at the moment?

**06:35 Bobbie:** Uh, 86 kilos thereabouts.

**06:40 Marie:** About the same? Okay. That's pretty good considering you've just gone through Christmas as well. I always find people say "Oh, I put on after over the festive period." So no, that, that is good. It might also be the medication as well, as, you know, it can increase your metabolism a little bit. So um, but as long as it's stable and you're not, you're not dropping weight. And everything all right with your mental health and things and your mood at the moment?

**07:07 Bobbie:** Yeah, fine, no problems there.

**07:09 Marie:** Fantastic. Okay. And um, everything the same with I think you said you just drink alcohol at the weekend and you just have three units?

**07:19 Bobbie:** Uh, or three, three drinks, so that's might be six, that's what kind of my cap what I try to stick to on any one night, but yeah, weekends, obviously a bit more over Christmas, but yeah.

**07:31 Marie:** Yeah, yeah. Okay, that's great. Okay. So observations are looking fine, Bobbie. Um, no concerns there. Um, so if, if it's okay with you, I'd like to increase your Elvanse to the next level, so we go to 40 milligrams a day. Um, so what we would do, we'll do your prescription, take that for another sort of four weeks and then we'll book you in again. And if you need the next dosage, we just do the same again, we check your observations and then we can go to a 50 milligram dosage.

**08:08 Bobbie:** What's the kind of where do you normally kind of get up to with this? What's the kind of therapeutic...

**08:15 Marie:** I would say every patient is different. Now obviously you're male, males, you know, typically tend to require a bigger dosage because you weigh more. Um, the maximum I'd say we go up to is about 70. Um, now what sometimes happens is if patients are noticing that despite being on the full dose of 70, that perhaps the medication isn't lasting them through the day, we sometimes add an immediate-release top-up in the afternoon. Not everybody needs it though because in theory, Elvanse should be in the system for 12 hours. So, you know, ideally you would expect if you were on 70 milligrams, you took that at 6:00 AM in the morning, you shouldn't be wearing off till 6:00 PM. But some people describe like a crash period in the afternoon and their concentration dips, they become irritable, they become dysregulated. If that were to happen, we would give you an immediate-release sort of midday, afternoon, because that only lasts in the system for four to six hours. Having said that, I have got some patients that are on a split dose of Elvanse. So they take it at 2:00 PM, the second dose, and it doesn't affect their sleep. So everybody is different. Um, so some get insomnia from it, some don't. Some patients it helps them sleep. And I guess the difficulty we have is we don't know how each patient is going to respond to things until we try all this. So the next step for you would obviously be, you're not having any any improvement from the moment you take it, let's go to the next dose in the morning, which would be 40. Still no improvement, we go to 50 and so on. If it is that you don't have a good response even though you are on full dosage of Elvanse, the next step would be looking at a non-stimulant, which is one called Atomoxetine. But generally speaking, patients don't usually go onto Atomoxetine unless the Elvanse is contraindicated, so usually Elvanse tends to work better than Atomoxetine for the majority of patients. Um, given that you did have a positive effect with Medikinet, I know the side effects were a bit grim, but the ADHD symptom profile, it did improve, didn't it, on Medikinet? There's a good chance that it will with Elvanse because again, it's a stimulant.

**10:56 Bobbie:** Yeah.

**10:57 Marie:** So are you happy for me to do the increase and then we have another appointment in about four weeks and see how you're getting on?

**11:08 Bobbie:** Um, yeah. Yeah. It was just last time I think when we spoke about it, because it can be quite long between kind of consultations, we kind of spoke about going up a bit further up to the because I'd kind of been okay on Medikinet and...

**11:21 Marie:** You, you can. Um, it's just the only thing I would be, would say, is you know because obviously it's a strong stimulant. Sometimes when patients do the 20 milligram increase, they might get that uncomfortable nausea, the headaches and things like that. Some people have vomiting. So I'm happy to do 50 milligrams, obviously your observations are fine, but just bear in mind you might get some of those side effects just because we've, we've done a bigger jump.

**11:53 Bobbie:** Yeah.

**11:54 Marie:** So are you, are you happy with that?

**11:57 Bobbie:** Yeah, yeah.

**11:58 Marie:** All right. If you do...

**11:59 Bobbie:** It just seems like a long time to have been on this and I've been kind of, yeah.

**12:03 Marie:** I know. I know. I know. If you do have any problems and you feel horrendous, save the 50s and I'll do you a prescription for the 40s and we'll get, we'll bridge a gap. But hope, hope, hopefully you'll be okay. I know a lot of patients, even though Elvanse is a strong stimulant and it lasts in the system for a while, patients do find the side effect profile a bit gentler than the Medikinet.

**12:31 Bobbie:** Yeah, definitely, yeah.

**12:33 Marie:** Hopefully you'll be okay. But if you do start feeling dreadful, just don't take the next day's dosage, send us an email immediately and we'll, we'll get you that prescription ready. Um, again, with the Elvanse, if you do want to have a break at the weekend, if you're having a drink, just have a break on the day you're drinking, get back on it whenever you want to. As long as you don't have more than four days off it, it's absolutely fine.

**13:02 Bobbie:** Yes, yeah.

**13:04 Marie:** All right. Um, is there anything else you wanted to ask today?

**13:08 Bobbie:** No, no. I think we're all good.

**13:10 Marie:** Okay. So I'll do the prescription, it'll be at the Benet Center, it'll be Monday um, after 1:00. Um, so if you're able to collect it um, anytime then, um, and then just get started on the medication the following day. And just, you know, take your 30s in the meantime.

**13:32 Bobbie:** Yeah, just saved that in my calendar so I don't forget it.

**13:35 Marie:** Yeah, no worries. All right then Bobbie. Well, um, lovely catching up with you again. It is likely you might see Laura next time.

**13:44 Bobbie:** Yeah.

**13:45 Marie:** But if Laura has any questions, she just comes and checks with me anyway, but she's very, very experienced lady, um, you know, prescriber, so you're in good hands, okay?

**13:56 Bobbie:** Yeah, no problem.

**13:58 Laura:** Nice to meet you Bobbie. Take care.

**14:00 Bobbie:** Yeah, and you. I'll see you the next time.

**14:02 Marie:** Yeah, okay. All right, thank you. Bye-bye.

**14:04 Laura:** Bye.

**14:05 Bobbie:** Bye.