NR 546 Week 7 Case Study- child and adolescent
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.
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 1 / 2
NR 546 Week 7 Case Study- child and adolescent
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 anxiety • One brother age 7, alive and well Social History • Lives with parents and brother • 1 st grader at local public school • does 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
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
- / 2