NR 546 Week 7 Case Study- child and
adolescent
Subjective Objective
The client is a 6-year-old male accompanied Physical Examination:
by his mother and 10-year-old brother.
Physical Examination (Obtained by Pediatrician 2 Days
Earlier) Height 48″, weight: 65 lb, BMI: 23.9
Client’s Chief Complaints:
Vital signs: B/P, 100/60; P, 78; R, 16; T, 98.4
“My son is getting in trouble at school. He
has endless energy, he can’t sit still. When General: Well-nourished 7-year-old male
he plays, he 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
Pulmonary: No wheezing, rhonchi, or
academic and behavioral concerns. The
mother presents a school report that states
rales Cardiac: S1, S2
that he cannot stay seated, frequently calls
out in class, is disorganized, cannot complete Abdomen: No distension, bowel sounds × 4 quadrants, no
his assignments, and has been known to be masses or hernias
disrespectful to adults.
Lymph nodes: No swelling
According to his mother, he is very
impatient, distractable and impulsive Extremities: 2+ pulses
bilaterally Skin: No lesions
Past psychiatric history: . At age 4, the child
was in a Head Start Program, and it was or edema Neuro: CN II-XII
noted that he was demonstrating extreme
intact
hyperactivity, poor impulse 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.
adolescent
Subjective Objective
The client is a 6-year-old male accompanied Physical Examination:
by his mother and 10-year-old brother.
Physical Examination (Obtained by Pediatrician 2 Days
Earlier) Height 48″, weight: 65 lb, BMI: 23.9
Client’s Chief Complaints:
Vital signs: B/P, 100/60; P, 78; R, 16; T, 98.4
“My son is getting in trouble at school. He
has endless energy, he can’t sit still. When General: Well-nourished 7-year-old male
he plays, he 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
Pulmonary: No wheezing, rhonchi, or
academic and behavioral concerns. The
mother presents a school report that states
rales Cardiac: S1, S2
that he cannot stay seated, frequently calls
out in class, is disorganized, cannot complete Abdomen: No distension, bowel sounds × 4 quadrants, no
his assignments, and has been known to be masses or hernias
disrespectful to adults.
Lymph nodes: No swelling
According to his mother, he is very
impatient, distractable and impulsive Extremities: 2+ pulses
bilaterally Skin: No lesions
Past psychiatric history: . At age 4, the child
was in a Head Start Program, and it was or edema Neuro: CN II-XII
noted that he was demonstrating extreme
intact
hyperactivity, poor impulse 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.
