Adolescent Case Presentation

choose a case or disorder and Create a Focused SOAP Note/case presentation of a child or Adolescent. Use the attached template.

Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

PRAC 6665: PMHNP Care Across the Lifespan I

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint):

HPI:

Substance Current Use: 

Medical History: 

· Current Medications:

· Allergies:

• Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Diagnostic Impression:

PRIMARY DIAGNOSIS

3 DIFFERENTIAL DIAGNOSIS

Reflections:

Case Formulation and Treatment Plan:

Week 8: Child/Adolescent Case Presentation – ADHD

Student Name: [Your Name] College of Nursing-PMHNP, Walden University PRAC 6665: PMHNP Care Across the Lifespan I Faculty Name: [Faculty Name] Assignment Due Date: [Due Date]

Subjective:

CC (chief complaint): Parental concern regarding behavioral issues and poor attention in school.

HPI: The patient is an 8-year-old boy, brought to the clinic by his parents, who report concerns about his behavior. According to the parents, the child has difficulty staying focused on tasks and following instructions, both at home and in school. He is often forgetful, loses belongings, and is easily distracted. The child’s teacher also reported that he frequently disrupts the class and has difficulty completing assignments. The parents noticed these difficulties started around the age of 5 and have been progressively getting worse. They are worried about his academic and social functioning.

Substance Current Use: No substance use as the patient is a child.

Medical History:

· Current Medications: None

· Allergies: No known allergies

Reproductive Hx: Not applicable as the patient is a child.

ROS:

· GENERAL: No significant weight loss or fever.

· HEENT: No vision or hearing problems.

· SKIN: No rashes or skin issues.

· CARDIOVASCULAR: No known cardiac issues.

· RESPIRATORY: No respiratory complaints.

· GASTROINTESTINAL: No gastrointestinal complaints.

· GENITOURINARY: No genitourinary issues.

· NEUROLOGICAL: Apart from the presenting complaints, no seizures or neurologic issues reported.

· MUSCULOSKELETAL: No musculoskeletal complaints.

· HEMATOLOGIC: No bleeding disorders.

· LYMPHATICS: No significant lymphatic issues.

· ENDOCRINOLOGIC: No known endocrine disorders.

Objective:

Diagnostic results: The patient’s teacher completed the Vanderbilt ADHD Diagnostic Rating Scale, and the results indicate high scores on inattentiveness, impulsivity, and hyperactivity subscales, suggestive of Attention-Deficit/Hyperactivity Disorder (ADHD). The child’s academic performance also showed a decline over the past year.

Assessment:

Mental Status Examination: The patient appears age-appropriate and well-groomed. His speech is normal in rate and tone. He is cooperative during the assessment. No signs of hallucinations or delusions are noted. The child has difficulty sustaining attention during the interview and is easily distracted.

Diagnostic Impression: Based on the subjective and objective findings, the primary diagnosis is Attention-Deficit/Hyperactivity Disorder (ADHD), Predominantly Combined Presentation.

3 Differential Diagnoses:

1. Oppositional Defiant Disorder (ODD): Children with ODD often display a pattern of angry or irritable mood, argumentative behavior, and defiance, which could overlap with ADHD symptoms.
2. Specific Learning Disorder (SLD): Poor academic performance may be caused by a learning disorder rather than ADHD.
3. Conduct Disorder (CD): Some behaviors, such as disruptive behavior and aggression, could be indicative of CD in addition to ADHD.

Reflections:

This case highlights the common presentation of ADHD in a child, with difficulties in attention, impulsivity, and hyperactivity affecting both academic and social functioning. Proper evaluation is crucial to differentiate ADHD from other possible disorders that may present with similar symptoms.

Case Formulation and Treatment Plan:

The patient’s diagnosis of ADHD, Predominantly Combined Presentation, necessitates a comprehensive treatment plan. Treatment will include a combination of behavioral interventions and pharmacotherapy. For behavioral interventions, parent training in behavior management techniques will be essential to address the child’s behavior at home and support them in school.

In addition to behavioral interventions, stimulant medication, such as methylphenidate, may be considered to improve attention and reduce hyperactivity. Close monitoring and follow-up will be necessary to adjust medication dosage and assess treatment response and any side effects.

Collaboration with the school is crucial to implement behavioral strategies in the educational setting, ensure appropriate accommodations, and monitor the child’s progress. Regular follow-up visits will be scheduled to evaluate treatment effectiveness and make any necessary adjustments.

It is essential to involve the parents and teachers in the treatment process and provide them with resources and support to help the child manage their symptoms effectively both at home and at school. Additionally, addressing any comorbid conditions, such as anxiety or learning disorders, may be necessary to optimize treatment outcomes.

In conclusion, ADHD is a complex disorder with significant implications for a child’s academic, social, and emotional development. Early recognition and evidence-based interventions can improve the child’s overall functioning and quality of life.