ihuman case study week 14 – writinghub.net

Please rewrite this case study below as the format attached. I need it as soon as you can and in the format attached. please add additional fluff, information to make it more scholarly.

Patient Information: BJ, 13-year-old, Caucasian male
CC: “I hate school”
HPI: BJ presents with his mother, who reports behavioral problems at home and school. According to his teachers, he is distracted, disruptive and forgetful. He has difficulty focusing, following directions and waiting his turn. His bag for school, desk, and locker are a mess. He is often unprepared for class and fails to complete homework assignments. When the teacher reminds him about the homework, he gets upset and snaps at her. He does not follow directions or complete his chores at home, especially when he is assigned more than one task at a time.
Current Medications: None
Allergies: NKDA
Past Medical History
Unremarkable, immunizations up-to-date
Social History
Full-time student
Recreational drug: denies
Independent for ADLs
Lives at home with mother

Parents recently divorced (one month ago), visits dad one weekend
a month
No known history of sexual or physical abuse or psychological trauma
Family History
Paternal: living, hx of cocaine abuse

ROS
ROS unremarkable
EXAM
VS: BP: 108/76 sitting, 104/68 standing, 80 pulse, regular, respirations: 16 temperature 98.2 SpO2: 99% weight: 120 lbs. height: 5’ 4” BMI: 20.6
OBJECTIVE
Physical exam unremarkable
MSE
Appearance: dress is appropriate for environment, situation, and stated age
Behavior/Activity: fidgety throughout consultation
Speech: spontaneous, coherent with appropriate volume, tone, and rate
Thought form: logical and goal directed
Thought content: no auditory hallucinations or delusions noted
Mood: euthymic
Affect: irritable, improves as consultation progresses
Suicidal Ideation: none
Homicidal Ideation: none
Orientation: A/O x 3
Memory: immediate, recent, and remote memory intact
Judgment/Insight: fair
Attention/Concentration: distracted, does not focus on interviewer and requires questions be repeated
SCREEINGS
MMSE: cognitive errors noted, spelled WORLD backwards and serial 7s incorrect
DIAGNOSTICS
Urine toxicology screen: negative

DIAGNOSIS
Attention-deficit hyperactivity disorder, predominantly inattentive type, F90.0
BJ meets criteria for this diagnosis as evidenced by behaviors listed below, which are manifested both at school and at home:
• Repeated thoughtless schoolwork mistakes
• Difficulty maintaining attention
• Difficulty completing schoolwork
• Ineffective time management
• Forgetfulness related to daily activities
• Repeatedly loses essential school equipment
(American Psychiatric Association, 2013)

PLAN
Obtain baseline weight, BP, pulse, EKG, and Vanderbilt ADHD scale
Have parents and teachers complete Vanderbilt ADHD scale prior
to each follow-up visit
Tutoring as needed
Daily physical activity (at least 60 minutes)
Refer for mindfulness therapy
Start methylphenidate ER 18mg PO daily (Wolters Kluwer, 2019)
EDUCATION
As the nurse practitioner, I would provide the patient and family with education pertaining to the following:
• Diagnosis
• Medications
• Monitoring for stimulant side effects
• Vanderbilt ADHD scale
• Importance of collaborative care, including teacher, father, and PMHNP
• Benefits of psychotherapy

REFERRAL
Referral to psychotherapist for mindfulness therapy
FOLLOW-UP
One week or sooner for medication management and supportive therapy

References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Publishing.

Wolters Kluwer. (2019). Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis. Retrieved August 11, 2019, from https://www.uptodate.com/contents/attention-deficit-hyperactivity-disorder-in-children-and-adolescents-overview-of-treatment-and-prognosis?search=adhd%20treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

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