NR 546 Week 7 Case Study- child and adolescent
Subjective Objective
The client is a 6-year-old male accompanied by his Physical Examination:
mother and 10-year-old brother.
Physical Examination (Obtained by Pediatrician 2 Days Earlier)
Client’s Chief Complaints: Height 48″, weight: 65 lb, BMI: 23.9
“My son is getting in trouble at school. He has Vital signs: B/P, 100/60; P, 78; R, 16; T, 98.4
endless energy, he can’t sit still. When he plays, he General: Well-nourished 7-year-old male
is too rough with other kids.”
HEENT: PERRLA, EOMI, vision is 20/20, and hearing acuity is
unremarkable.
History of Present Illness
Neck: No masses
The mother presents with the client due to
academic and behavioral concerns. The mother Pulmonary: No wheezing, rhonchi, or rales
presents a school report that states that he cannot
stay seated, frequently calls out in class, is Cardiac: S1, S2
disorganized, cannot complete his assignments, and
Abdomen: No distension, bowel sounds × 4 quadrants, no masses
has been known to be disrespectful to adults.
or hernias
According to his mother, he is very impatient,
distractable and impulsive Lymph nodes: No swelling
Extremities: 2+ pulses bilaterally
Past psychiatric history: . At age 4, the child was in
a Head Start Program, and it was noted that he was Skin: No lesions or edema
demonstrating extreme hyperactivity, poor impulse Neuro: CN II-XII intact
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 5, he was evaluated and diagnosed
with ADHD, combined type. Medication was not
prescribed at that time due to age.
, Past Medical History: healthy Mental status exam:
Perinatal history: full term pregnancy, Appearance: well-nourished 6-year-old male who appears stated
uneventful. NSVD. Breastfed x 5 months. age. He is casually attired in a striped collared shirt, jeans, and
sneakers, appropriate for age and weather. Hygiene and grooming
Developmental: mother reports client
are good.
demonstrates age-appropriate gross and fine motor
skills. He is able to dress and undress, can tie his Alertness and Orientation: fully oriented to
shoes, colors within the lines; he can balance on person‚ place‚ time‚ and situation, Alert
one foot, catch a tennis ball, and ride a bicycle with
Behavior: He separates easily from his mother and brother to
training wheels.
come with interviewer. When he enters the office, he sits down in
Family History the chair, puts his hands on the desk and states, “Let’s get to
work.” Initially, he stays seated with good posture, but after
• Father is alive and well.
several minutes, he becomes hyperactive and cannot stay seated.
• Mother is alive, has anxiety
Boundaries are poor, and he often grabs objects off the desk. He
• One brother age 10, alive and well frequently interrupts.
Social History
Speech: Speech is spontaneous. At times, tone is loud. Rate is
• Lives with parents and brother fast, and he talks excessively. He has a mild lisp and some age-
• 1st grader at local public school appropriate articulation errors.
• does not have any friends Mood: “happy”
Trauma history: no reports of trauma
Affect: constricted
Review of Systems
Impulse control: Poor. Touching items on provider’s desk despite
• appetite good, weight stable multiple reprimands from his mother.
• sleeps 5-7 hours at night, difficulty
Thought content: Suicidal and/or homicidal ideations: Cannot be
falling asleep
elicited when questioned
Allergies: NKDA
Perceptions: No evidence of psychosis, not responding to internal
stimuli, reports auditory hallucinations.
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
Subjective Objective
The client is a 6-year-old male accompanied by his Physical Examination:
mother and 10-year-old brother.
Physical Examination (Obtained by Pediatrician 2 Days Earlier)
Client’s Chief Complaints: Height 48″, weight: 65 lb, BMI: 23.9
“My son is getting in trouble at school. He has Vital signs: B/P, 100/60; P, 78; R, 16; T, 98.4
endless energy, he can’t sit still. When he plays, he General: Well-nourished 7-year-old male
is too rough with other kids.”
HEENT: PERRLA, EOMI, vision is 20/20, and hearing acuity is
unremarkable.
History of Present Illness
Neck: No masses
The mother presents with the client due to
academic and behavioral concerns. The mother Pulmonary: No wheezing, rhonchi, or rales
presents a school report that states that he cannot
stay seated, frequently calls out in class, is Cardiac: S1, S2
disorganized, cannot complete his assignments, and
Abdomen: No distension, bowel sounds × 4 quadrants, no masses
has been known to be disrespectful to adults.
or hernias
According to his mother, he is very impatient,
distractable and impulsive Lymph nodes: No swelling
Extremities: 2+ pulses bilaterally
Past psychiatric history: . At age 4, the child was in
a Head Start Program, and it was noted that he was Skin: No lesions or edema
demonstrating extreme hyperactivity, poor impulse Neuro: CN II-XII intact
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 5, he was evaluated and diagnosed
with ADHD, combined type. Medication was not
prescribed at that time due to age.
, Past Medical History: healthy Mental status exam:
Perinatal history: full term pregnancy, Appearance: well-nourished 6-year-old male who appears stated
uneventful. NSVD. Breastfed x 5 months. age. He is casually attired in a striped collared shirt, jeans, and
sneakers, appropriate for age and weather. Hygiene and grooming
Developmental: mother reports client
are good.
demonstrates age-appropriate gross and fine motor
skills. He is able to dress and undress, can tie his Alertness and Orientation: fully oriented to
shoes, colors within the lines; he can balance on person‚ place‚ time‚ and situation, Alert
one foot, catch a tennis ball, and ride a bicycle with
Behavior: He separates easily from his mother and brother to
training wheels.
come with interviewer. When he enters the office, he sits down in
Family History the chair, puts his hands on the desk and states, “Let’s get to
work.” Initially, he stays seated with good posture, but after
• Father is alive and well.
several minutes, he becomes hyperactive and cannot stay seated.
• Mother is alive, has anxiety
Boundaries are poor, and he often grabs objects off the desk. He
• One brother age 10, alive and well frequently interrupts.
Social History
Speech: Speech is spontaneous. At times, tone is loud. Rate is
• Lives with parents and brother fast, and he talks excessively. He has a mild lisp and some age-
• 1st grader at local public school appropriate articulation errors.
• does not have any friends Mood: “happy”
Trauma history: no reports of trauma
Affect: constricted
Review of Systems
Impulse control: Poor. Touching items on provider’s desk despite
• appetite good, weight stable multiple reprimands from his mother.
• sleeps 5-7 hours at night, difficulty
Thought content: Suicidal and/or homicidal ideations: Cannot be
falling asleep
elicited when questioned
Allergies: NKDA
Perceptions: No evidence of psychosis, not responding to internal
stimuli, reports auditory hallucinations.
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
