NRNP 6635 Assignment: Assessing and Diagnosing Patients With Neurocognitive and Neurodevelopmental Disorders
Subjective:
CC (chief complaint): “psychiatric evaluation of attention deficit hyperactivity disorder.”
HPI: The 9-year-old female patient was accompanied to the psychiatric department by her mother following the positive findings of the completed attention deficit hyperactivity disorder (ADHD) questionnaire. The patient’s teacher also got an opportunity to complete the ADHD questionnaire based on her behavior and habits at school. According to the patient’s mother, her daughter has displayed difficulties in paying attention and is always forgetful. The patient’s teacher also reports similar symptoms at school, as the patient frequently forgets her assignments. At school, the patient fidgets a lot, displaying difficulties in sitting still on a chair. Additional symptoms reported include daydreaming, temperamental, and engaging in injurious activities. The patient started experiencing the above symptoms when she joined the kindergarten. Her mother claims that no treatment approach has been used so far in the management of the patient’s symptoms.
Past Psychiatric History:
- General Statement: The patient presents with attention deficit and memory problems which affect her academic performance and other daily activities.
- Caregivers (if applicable): The 9-year-old girl is under the care of one of her mothers.
- Hospitalizations: No history of hospitalization was reported.
- Medication trials: No medication has been used to manage the patient’s current symptoms.
- Psychotherapy or Previous Psychiatric Diagnosis: The patient has never been diagnosed with a mental disorder or taken part in therapy.
Substance Current Use and History: The patient lives and studies in a drug-free environment, with no exposure to cigarette or marijuana smoke.
Family Psychiatric/Substance Use History: No history of mental disorder or use of substances has been reported among any family member.
Psychosocial History: The patient is the only kid, who was being raised by her two moms. However, they recently got separated to resolve their marital issues, leaving the patient to stay with one, the current historian. The patient is in the 3rd grade, with poor performance due to her mental condition. She gets adequate sleep every night, for about 9 hours. Her PCP reports that the patient displays difficulties in consuming an entire meal as a result of being unable to sit down but she manages to get proper nutrition. She has a dog and also likes visiting art galleries and playing video games.
Medical History: No history of any chronic medical condition was reported.
- Current Medications: The patient is not on any medication.
- Allergies: No known food, environmental, or drug allergies.
- Reproductive Hx: Mother reports normal birth, with no birth defects. No family history of reproductive disorders.
ROS:
- GENERAL: Generally healthy with no recent changes in body weight. Denies fever, chills, fatigue, headache, lethargy, or dizziness.
- HEENT: Head: denies headache. Even distribution of hair. No signs of injury or trauma. Eyes: No redness, excessive tearing, itchiness, polyploidy, or pain. Ears: No tinnitus, hearing loss, inflammation, itchiness, or exudates. Nose & Throat: No congestion, sinus problems, bleeding nose, running nose, inflammation, or itchiness. No sore throat, swallowing difficulties, or bleeding gums.
- SKIN: Warm but somehow dry. No lesions, bruises, lumps, redness, inflammation, or eczema.
- CARDIOVASCULAR: No palpitations, murmurs, chest tightness, cyanosis, syncope, arrhythmias, or hypertension.
- RESPIRATORY: No running nose, congestion, breathing difficulties, sneezing, wheezing, cough, sputum production, asthma, or chest discomfort.
- GASTROINTESTINAL: No tenderness, hernia, abdominal distension, diarrhea, constipation, nausea, or vomiting.
- GENITOURINARY: No urgency, frequency, or burning sensation when urination or incontinence. Has not yet experienced her first menses.
- NEUROLOGICAL: No ataxia, headache, heat or cold intolerance, reduced appetite, paresthesia, or dizziness.
- MUSCULOSKELETAL: No muscle or joint tenderness, stiffness, or inflammation. Confirm full range of movement in both lower and upper extremities.
- HEMATOLOGIC: Denies easily bruising, bleeding gums, nose bleeding, anemia, or any other hematological disorde