NR 546 Week 7 Case Study- child and adolescent Subjective…
NR 546 Week 7 Case Study- child and adolescent
Subjective
Objective
The patient is a 6-year-old male accompanied by his mother and 7-year-old brother.
Patient’s Chief Complaints:
“My son is like the energizer bunny. When he plays, he is too rough with other kids.”
History of Present Illness
This boy was previously diagnosed with attention-deficit/hyperactivity disorder (ADHD). The school reports that he cannot stay seated, frequently calls out in class, is disorganized, cannot complete his assignments, and has been known to be disrespectful to adults. According to his mother, he is very impatient and impulsive. At age 3, the child was in the Head Start Program, and it was noted that he was demonstrating extreme hyperactivity, poor impulse control, and difficulty sustaining focus. Peer interactions were marked by aggression such as kicking and biting others. When told “no,” he would have extreme temper tantrums, where he would cry, scream, and destroy property. Such behaviors resulted in being permanently expelled from the program. At age 4, he was evaluated and diagnosed with ADHD, combined type. Medication was not prescribed at that time due to age.
Past psychiatric history: previously diagnosed with attention-deficit/hyperactivity disorder (ADHD). No medications.
Past Medical History: healthy
Perinatal history: full term pregnancy, uneventful. NSVD. Breastfed x 5 months.
Developmental: mother reports client demonstrates age-appropriate gross and fine motor skills. He is able to dress and undress, can tie his shoes, colors within the lines; he can balance on one foot, catch a tennis ball, and ride a bicycle with training wheels.
Family History
Father is alive and well.Mother is alive, has anxietyOne brother age 7, alive and well
Social History
Lives with parents and brother1st grader at local public schooldoes not have any friends
Trauma history: no reports of trauma
Review of Systems
appetite good, weight stable sleeps 5-7 hours at night, difficulty falling asleep
Allergies: NKDA
Physical Examination:
Physical Examination (Obtained by Pediatrician 2 Days Earlier)
Height: 3′8″, weight: 65 lb, BMI: 23.9
Vital signs: B/P, 100/60; P, 78; R, 16; T, 98.4
General: Well-nourished 6-year-old male
HEENT: PERRLA, EOMI, vision is 20/20, and hearing acuity is unremarkable.
Neck: No masses
Pulmonary: No wheezing, rhonchi, or rales
Cardiac: S1, S2
Abdomen: No distension, bowel sounds × 4 quadrants, no masses or hernias
Lymph nodes: No swelling
Extremities: 2+ pulses bilaterally
Skin: No lesions or edema
Neuro: CN II-XII intact
Mental status exam:
Appearance: well-nourished 6-year-old male who appears stated age. He is casually attired in a striped collared shirt, jeans, and sneakers, appropriate for age and weather. Hygiene and grooming are good.
Alertness and Orientation: fully oriented to person‚ place‚ time‚ and situation, Alert
Behavior: He separates easily from his mother and brother to come with interviewer. When he enters the office, he sits down in the chair, puts his hands on the desk and states, “Let’s get to work.” Initially, he stays seated with good posture, but after several minutes, he becomes hyperactive and cannot stay seated. Boundaries are poor, and he often grabs objects off the desk. He frequently interrupts.
Speech: Speech is spontaneous. At times, tone is loud. Rate is fast, and he talks excessively. He has a mild lisp and some age-appropriate articulation errors.
Mood: “happy”
Affect: constricted
Impulse control: Poor.
Thought content: Suicidal and/or homicidal ideations: Cannot be elicited when questioned
Perceptions: No evidence of psychosis, not responding to internal stimuli, reports auditory hallucinations.
Memory: .Memory: Remote memory appears fair. He is able to repeat three objects immediately but not after 5 minutes.
Concentration: When focused, he is able to sing the ABC’s and count to 99. Otherwise, he has a very short attention span and is distracted.
Attention and observed intellectual functioning: Intelligence appears to be average.
Fund of knowledge: Good general fund of knowledge and vocabulary
Musculoskeletal: normal gait and station
Diagnosis: (F90.2) Attention-Deficit/Hyperactivity Disorder, Combined Presentation
Select one drug to treat the diagnosis(es) or symptoms.List medication class and mechanism of action for the chosen medication.Write the prescription in prescription format.Provide an evidence-based rationale for the selected medication using at least one scholarly reference. Textbooks may be used for additional references but are not the primary reference.List any side effects or adverse effects associated with the medication.Include any required diagnostic testing. State the time frame for this testing (testing is before medication initiation or q 3 months, etc.). Include normal results range for any listed laboratory tests.Provide a minimum of three appropriate medication-related teaching points for the client and/or family
