Subjective Objective
M.K.'s mother brings her in with concerns Physical Examination:
about M.K.'s inability to focus, excessive
Physical Examination (Obtained by Pediatrician 2 Days
fidgeting, and impulsive behavior both at home
Earlier)
and in school.
Vital Signs: Temperature 98.6°F, heart rate 90 bpm,
Client’s Chief Complaints:
respiratory rate 18 bpm, blood pressure 110/70 mmHg.
"M.K. is frequently disruptive in school and is
struggling academically. Her behavior has led General: Well-nourished, alert, and cooperative.
to failing grades, and the school has issued a
warning that she may face suspension if her HEENT: Normocephalic, atraumatic, pupils equal, round,
and reactive to light, no ear discharge, throat clear.
disruptive behavior continues." Additionally,
mother reports M.K. is not passing any of her
Cardiovascular: Normal heart sounds S1, S2, no murmurs.
courses and fails to turn in homework
assignments she has completed. Respiratory: Clear breath sounds bilaterally, no wheezes or
History of Present Illness crackles.
Abdomen: Soft, non-tender, no masses.
M K. has had difficulty concentrating and
staying seated in class since starting school. Her
Musculoskeletal: Normal gait, full range of motion.
teachers report that she often interrupts others,
is easily distracted, and has trouble completing
Neurological: Alert and oriented, normal reflexes and
tasks. These symptoms have been persistent for
the past two years and have been affecting her muscle tone. CN II-XII intact
academic performance and social interactions. Skin: No lesions or edema
Mother notes that M.K.'s academic performance
has significantly declined over the past school
year, despite her efforts to provide support and
encouragement at home. She reports that M.K.
often expresses frustration and self-doubt about
her abilities, leading to feelings of low self-
9.24 MWS