Navigating Pediatric ADHD: NRNP 6665 Week 9: PMHNP Care Across The Lifespan I

Subjective:

CC (chief complaint): The patient mother complain about her daughter is displaying some abnormal behavior at home and the teachers also complained to the mother that she is very disruptive  and barely finish individual work in school

 

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HPI: The patient is a 7 year old African American female who was brought by her mother due to hyperactive, lack of concentration, and impulsiveness that she noticed since she was 5, but the mother thought is normal for her age because she was her first child.  The mother rate her symptom to 7/10 on the rate of the scale of 1-10 (10 being the worst). He sometimes display some aggression toward her younger brother and some mood swing.  Also always play too much without focusing on what she is doing.  The teacher also mentioned that she barely finish her work in school and sometimes her mind will not be in class.

Substance Current Use: Mother denies any substance use or second hand use.

Past psychiatric history: Denies

Medication trials and current medications: None

Psychotherapy or previous psychiatric diagnosis: None

Family psychiatric history: Patient’s paternal cousin has ADHD. Mother has history of post-partum depression. No suicide, or unknown death before 30 years old.

Medical History:  None

Allergies: Amoxicilline

Reproductive Hx: N/A.

Psychosocial: The patient was born and raised in Canton Texas.  She is currently in 2rd grade in private school. She has one younger brothers. Her parents have been married for 9 years. No emotional or physical trauma.  She has a good relationship with her father.  She likes playing with her tablet, playing with friend at school and play ground. She also like riding bicycle with friends and her brother.

ROS:

  • GENERAL: No weekness, chills or fever noted.
  • HEENT: Patient denied any head injuries, Eyes: No eye pains problems. Ear: Denies earache. Nose: rhinorrhea reported. Throat: No sore throat.
  • SKIN: Eczema noted
  • CARDIOVASCULAR: No cardiac issue or chest pain noted
  • RESPIRATORY: Denies any SOB or coughing
  • GASTROINTESTINAL: No abdominal discomfort
  • GENITOURINARY: No painful urination or flank pain reported.
  • NEUROLOGICAL: No instability movement, numbness or paralysis noted
  • MUSCULOSKELETAL: No broken bone or muscle soreness reported.
  • HEMATOLOGIC: No abnormal bleeding, anemia or fatigue reported
  • LYMPHATICS: No lymph node enlargement.
  • ENDOCRINOLOGIC: Denies any excessive urination or excessive sweating.
  • PSYCHIATRIC: Mother reports hyperactive, impulsive, aggressive and inability to focus.

Objective:

Diagnostic results:  CBC, BMP

BP: 118/76, Pulse: 80, PSO2: 99%, Temp: 97.6 *F

Assessment:

Mental Status Examination: Pt. is 7 year old African American female who presented to the office with her mother due to her hyperactivity, impulsiveness, aggression, and lack of focus in school.  Patient denies any nightmares at night or sleep problems.  She was alert during the appointment, but seems hyperactive and unstable mind when ask some questions.  Mother answers all the questions.  She denies any suicidal thoughts and was not a good reliable historian for some questions due to her age.

Diagnosis/Diagnoses – include all mental health diagnoses and the ICD-10 codes for each.  Be Specific with diagnosis. Example: Major depressive disorder, recurrent, moderate F33.1; General anxiety disorder F41.1

  • At least three differentials with supporting evidence. List them from top priority to least priority.)

Reflection

Discuss what you learned and what you might do differently. Include a brief rationale for your treatment plan.  You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differential diagnoses and treatment plan.  Compare the DSM-5-TR diagnostic crit

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