Assignment: Writing Treatment Notes

Chief complaint: Grades have been getting worse and patient has difficulty listening to teachers.

Patient admits not to like any particular subjects especially math’s. He finds history more appealing but still cannot concentrate well in class because he is somehow distracted by something.

Patient admits to not playing any sports and says that whilst he participated in basketball and baseball in high school he thinks he can’t find time now and with his performance in school, the mother would allow sports.

Admits to forgetting his homework frequently either because he forgot a notebook, the pen, or some needed material

He feels that he is disappointing his mother but admits he can do very little to change that because he feels he has no control over it

Patient admits to having a not-close relationship with his father or his other sibling (sister)

Patient admits to enjoying video games because they are fun and distracts him from the normal life. He likes outdoor activities but engages in them so that he can be a bit active and ‘mum doesn’t think he isn’t doing anything’

Admits to limited sleeping time due to video games but sees no connection to his school performance and concentration issues

(UMass Nursing 690M, 2016)

Patient can remember the three words and repeat them again few minutes later.

Patient can spell the provided word appropriately (UMass Nursing 690M, 2016)

Mental status exam

Orientation: Alert and oriented x 3

Appearance: The patient was appropriately dressed, and appeared his stated age.

Speech and language: The patient’s speech was slightly fast.

Attitude: The patient was cooperative and calm

Mood: Anxious

Concentration: Impaired concentration

Thought processes and associations: Logical and coherent

Suicidal/homicidal ideations: The patient had no homicidal or suicidal ideations.

Memory: Intact

Insight: Altered

Judgement: Poor

Differential diagnosis:

1. Attention deficit hyperactivity disorder (ADHD), Unspecified Type. ICD-Code F90. 9

2. Anxiety Disorder, Unspecified. ICD-Code F41. 9

3. Obsessive-compulsive disorder, unspecified ICD-Code F42. 9 (Carr et al., 2016)

Primary diagnosis:

Attention deficit hyperactivity disorder (ADHD), Unspecified Type. ICD-Code F90. 9 (Carr et al., 2016)

As evidenced by manifestation of more than five symptoms for over five months including but not limited to lacking attention to detail, difficulty in sustaining attention, easily distracted, poor organization/forgetfulness, and restlessness (American Academy of Family Physicians, 2019)

Obstacles to treatment:

Patient has a problem with forgetfulness which could affect medication adherence.

The absence of a close relation for psychological support and to help in self-organization and self-management such as a sibling limits chances for optimal outcomes (Nimmo-Smith et al., 2020)

Cognitive Behavioral Therapy (CBT): The intention of CBT in ADHD is to train the brain to respond more appropriately to the primary roles of the patient’s life (Nimmo-Smith et al., 2020). In the patient’s case herein, the ADHD is affecting his studies and the role of CBT is to enable him shed off the negative elements influencing his behaviors and lifestyle (Nimmo-Smith et al., 2020). The CBT will be sustained for four weeks with a maximum of two sessions each week. Patient will be seen again in two weeks.

Patient Name: Cory

DOB : Patient reports he just turned 16 years old.

Sex : Male

Preference for pronouns: Not mentioned in video.

Location of interview : Living room.

People present for interview : DNP Nursing Student (Georgina) and Patient (Cory)

History of Present Illness : Reports difficulty concentrating in school. Reports grades are slipping. Reports he is easily distracted. Reports he regularly neglects to get his work done or to bring his books home. Reports little interest in his classes except from gy class and trades. Reports his instructors give him criticism that he makes “indiscreet missteps.” Reports he doesn’t take notes in class and assuming he does, he frequently neglects to bring notes home and experiences difficulty finishing his schoolwork. Reports frequent impulsivity, expressing that he frequently makes a minute ago arrangements with his friends. Reports low mood at present due to not having the option to play sports because of low evaluations. Reports getting a charge out of being truly dynamic outside

Reports he often forgets his passwords or loses things in his room.

Medical History : No prior medication used mentioned during interview. Denies prior hospitalizations. No mention of surgical procedures.

Psychiatric History: Denies prior psychiatric hospitalizations. Denies seeing counselor in the past. Denies any prior self-injurious behaviors. Denies suicidal or homicidal thoughts. Denies A/H. Possible differential diagnosis of attention deficient hyperactivity disorder.

Medication History : None

Social History : No current job. Legal history not mentioned. Lives with parents and sister. Current high school sophomore.

Substance Use : Not mentioned in video.

Allergies : Bees.

Mini Mental Status Exam: Patient was able to correctly spell the word world backwards, repeat three words immediately and recalled the three words after questions. Oriented to person, place, month, and year.

Risk assessment: Denies SI, SIB and HI. No reported history of domestic violence. Reports frustration due to his symptoms. Discussed differential diagnoses of ADHD. Due to his reported impulsivity, patient at risk for legal implications and future impulsive actions. According to Philipp-Wiegmann (2018), patients that are diagnosed with ADHD have a high-risk factor for criminal activity and legal difficulties, if not treated.

Screening results : No screening tools used in video.

Labs results : None

Vital signs : None

Review of Systems: Negative.

Differential diagnosis :

F90.9-Attention deficient hyperactivity disorder

F81.9-Developmental disorder of scholastic skills, unspecified F32.Depression

Medical diagnosis : None

Treatment options : Plan to review DSM-5 criteria for ADHD with patient to set up a formal diagnosis. . Academic testing to decide whether formative issue is available. Talk about both nonpharmacological and pharmacological designs for overseeing ADHD. Gain colateral from school to establish a plan. Think about IEP to help in individualized help.

Obstacles to treatment : Distraction and absent mindedness may imply that patient forgets to follow up with providers and attend appointments. May have disgrace encompassing psychiatric diagnosis.

Diagnosis: Utilize DSM-5 to confirm ADHD diagnosis. Rule out substance use disorder before prescribing a stimulant medication for ADHD to ensure safety of the patient.

Medication options : Consider Adderall to reduce symptoms of distractedness, impulsiveness, diminished school execution and hyperactivity (Stahl, Muntner and Grady, 2017). Start Adderall tablet, by mouth, 10mg and monitor for side effects and effectiveness. Prior to starting drug, the patient should be educated on the side effects as an afterthought impacts and the two guardians and child should agree to the prescription. Adderall may cause side effects of anorexia, dry mouth, weight reduction, sleep deprivation, irritability, tremors and dizziness. (Stahl, Muntner and Grady, 2017). Following one week of observing the 10mg dose it very well might be expanded by 10 mg if necessary for further effectiveness (Stahl, Muntner and Grady, 2017). Assignment: Writing Treatment Notes

Non-pharmacological interventions : Get collateral data with school counseling services just as his educators to guarantee an individualized plan for progress is made. Assess to decide whether IEP plan is required. Moore et al., (2016) report that pulling kids out of the classroom is disruptive for social working and IEP plans should take into consideration individualized in-class interventions for the best achievement. Obtain collateral data from guardians on his earlier presentation at school and the advancement of his present manifestations.

Referrals : Referral to obtain Neuropsychological Testing to assess for learning disability or ADHD diagnosis (Ng, Heinrich and Hodges, 2019). Referral to therapist for behavioral therapy interventions and kept monitoring of symptoms (Moore et al., 2016).

Complimentary therapies: Evaluate patient’s point of view on free treatments first. When to see patient next? I plan to meet this patient in about fourteen days to review neuropsychological testing results and confirm diagnosis. During that session, I plan on reviewing treatment alternatives.In the client decides to accept Adderall 10 mg, plan to meet in a week for evaluation.