Nr 602 Week 3 Case Study Part 1 – Adhd

NR 602 WEEK 3 CASE STUDY PART 1 – ADHD Attention-Deficit Hyperactivity Disorder-A Case Presentation Study for Week 3 NR602: Primary Care of the Childbearing and Childrearing Family Chamberlain University Fall 2018 Dwayne V. Ford, RN-BSN Week 3 SOAP NOTE Patient Information: A.F. (9 Y/O); Multiracial female, Medicaid (S) Subjective: CC: A.F. says “I can’t concentrate in school” and Mom states, “she just doesn’t seem to pay attention at home”. HPI: A.F is a 9 y/o female who presents with Mom for an acute appointment. Mother notes that patient started medication for ADD in January of this year. Over the last 2-3 weeks the patient's ability to focus has decreased and she has had a decrease in appetite. Mother notes that patient has lost weight, approximately five pounds. Mother says that A.F. does not exhibit signs of hyperactivity. She will sit and read a book or watch a TV show; furthermore, she does not have disciplinary problems at home or school. Patient is up to date on her immunizations. Current Medications: Adderall: 10 mg PO TID Allergies: No known allergies. PMHx: None PSHx: None. Immunization Hx: DTaP/HepB/IPV 4/20/15 Hepatitis B-3 dose 10/20/10 Hib PRP-T 10/20/10 Pneumococcal Conj (Prevnar 13) 10/20/10 Rotavirus Pentavalent 10/20/10 Polio 4/20/15 MMR 4/20/15 Varicella 4/20/15 Influenza 10/ Soc Hx: Social Screening: Current child-care arrangements: in home: primary caregiver is aunt/mother Sibling relations: sisters: 1 Parental coping and self-care: doing well; no major concerns Secondhand smoke exposure? No Fam Hx: Mother died d/t overdose; Father - unknown ROS: CONSTITUTIONAL: Alert and Oriented HEENT: No problems noted SKIN: None reported. CARDIOVASCULAR: None reported. RESPIRATORY: None reported. GASTROINTESTINAL: None reported. GENITOURINARY: None reported. NEUROLOGICAL: None reported. MUSCULOSKELETAL: None reported. HEMATOLOGIC/LYMPHATICS: None reported. PSYCHIATRIC: None reported. ENDOCRINOLOGIC: None reported. ALLERGIES: None reported. O: Vital signs: HR 88, RR 20, T 98.7 (oral) Pulse ox 98% Height 52”, weight 67 lb., BMI: 17.4, weight 49.5%, height 24.3% PHYSICAL EXAM Problem focused physical exam: General Appearance: Healthy-appearing, alert and oriented Head: Normocephalic Eyes: Sclera white, pupils equal and reactive, red reflex normal bilaterally Ears: Bilateral TM intact, light reflect WNL; Well-positioned, well-formed pinnae Nose: Clear, normal mucosa Throat: Lips, tongue, and mucosa are moist, pink and intact; palate intact Neck: Supple, symmetrical, no lymphadenopathy noted Chest: CTA, No wheezing or Rhonchi Psych: Unable to maintain focus on questions asked by this NP Student DIAGNOSTIC RESULTS: None available.