Subjective

The chief complaint of the patient is “I hate school”. The patient is called Billy Johnson and he is a 13-year-old male in school. The patient has been brought to the healthcare setting by her mother who points out that Billy has had a challenge in that he does not like going to school anymore. The mother as well as reported that her child has developed difficulties in having attention, being focused, and concentrating. The mother has pointed out that this has been seen by the teachers and the football coach who has affirmed that Billy has recently become so distractible. On having a physical examination, it is found that the child has normal development for a 13-year-old male child. There is no indication that the child has any signs of malnutrition or any facial dysmorphia. The child is observed to be having issues of fidgeting throughout the time that he is being examined. The teacher as well affirms that the locker, desk, and schoolbag are always messy. He always has to be reminded of his homework and he has had issues with misplacement of his belongings including his pencil and he is always ill-prepared for class. The mother has denied any indication that the child has issues of loss of appetite and that the main issue of concern is that he does not want to go to school.

The child points out that the reason that he does not want to go to school is that it makes him sad. The child is restless during some instances. The mother has affirmed that the child always feels anxious. The factor that helps in relieving his condition is not going to school. He points out that he feels better when he stays at home and he can sleep better during the weekend. The condition started the time that his mother and father divorced a year ago and he has a rough time being able to adjust. He ended up being irritable and denying to do chores but he has affirmed that at the moment he is doing better and that he is seen to be happy spending a weekend in a month with his father. The child has been affirmed to be having many friends who are considered to be nice but not top students in class.

The patient is not making use of any medication at the moment and he has not had any traumatic injuries or accidents. The mother argues that physically, the child is healthy and that the only issue of concern is the behavior of the child. He has always been able to do fairly well in her academic work but this has changed recently in that it has become worse. The mother argues that she in some instances gave the child melatonin at night to help in sleeping.

During his childhood, the child did not have any health complication that was considered to be out of the ordinary. The child did not experience any nonphysical or sexual abuse or any emotional traumatic events other. The only time that this changed was after his parents divorced and he has a great challenge. The child has always been healthy and a sturdy boy and he has always hit his developmental landmarks on time.

The child is at the moment not sexually active as per the mother but the mother has noticed that he has had a progressive development. On the family history, it is affirmed that Billy’s parents divorced a year ago and that he likes to stay at her mother’s place as he can play some games. He is however not facing any challenges staying with her father for one weekend.

On the social history of the child, it is expounded that Billy likes tea sports such as basketball and football. The child has been affirmed to be on the football team now but there has been an issue of complaints from the coach regarding the fact that the child does not follow instructions as required. The child has affirmed that he does not smoke or use alcohol and that he does not make use of any recreational drugs. His father is 43 years old and is healthy while his mother is 38 years old.

Include chief complaint, subjective information from the patient, names and relations of others present in the interview, and basic demographic information of the patient. HPI, Past Medical and Psychiatric History, Social History.

Objective                

The examination of Billy is carried out based on the fact that one can undertake the right basis and handle the right quality of information. The one thing that could be done for the betterment of the basis of commitment on the aspect of living for the population one can identify the aspect of decision making. The aspect of living is such that the child is seen to have had a quality life but is seen to be unable to adhere to any directions. The child as well is unable to concentrate when he is being examined. There is an issue of concern in that the child is found fidgeting. He is seen to be physically okay for his age and there is no indication that the child has any issues of concern about the aspect of having any failure in the physical growth of the child. The examination of the cardiovascular and the thyroid show that the results are unremarkable. The sex features of the child are observed to be appropriate for his age.

The mental examination of the child shows that he has an anxious mood. As such, the child has a challenge in being able to concentrate when he is being examined, and during the examination, the child is found to have issues of fidgeting and that he has distractions. The patient is faced with the challenge of being able to handle his behavior. The child is affirmed to have had a challenge in being able to ensure that his work is well organized. It is affirmed that he does not have a well-organized space in that his locker and his desk have been affirmed to be messy. The child does not have any issues with hallucinations or delusion. He as well does not have any suicidal ideations.

This is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative except…” Include MSE, risk assessment here, and psychiatric screening measure results.

Assessment

Attention Deficit hyperactivity disorder (ADHD): (ICD-10 F90.1): This is a mental health condition that is characterized by a person having a challenge being attentive, being hyperactive, and having impulsive nature (Rubia, 2018). The condition in many instances starts from childhood and persists to the time that one is an adult. The child with this condition will experience issues of low self-esteem and that one may have difficulty having friends. This is the primary diagnosis of Billy since it has been reported that he has become inattentive, and impulsive and that he is hyperactive.

Depressive disorder (ICD-10 F33.2): This is a continued mental health condition that is featured by cases of a person having a depressive mood, losing interest in activities, and that one may have a significant challenge of impaired day-to-day lifestyle. The condition as per Schramm et al. (2020) may arise from social distress or psychological distress that one may experience.

Generalized anxiety disorder (ICD-10 F41.1): DeMartini, Patel, and Fancher (2019) alludes that this is a mental health condition that is featured by an experience of severe, and continued issues of anxiety to the extent that the day-to-day livelihood and activities or a person are affected. This condition may occur at any age with the symptoms of a person being similar to a panic attack. The person experiences cases of worry that is constant and that one is restless. The child has affirmed that there are challenges of one experiencing trouble in concentration as well as is seen in the case of Billy.

Include your findings, diagnosis, and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.

Plan

1 Treatment plan

The process of treatment of Billy will be carried out by the consideration of the use of both medication and therapeutic measures. The proposed therapy is the use of cognitive behavior therapy that will be ideal for the change of the negative behavior of the child and help in the improvement of his concentration.

2. Medication

The medication that will be proposed to be used in the case of Billy is a stimulant. This is the preferred medication as it will help in reducing the negative thoughts and the impulsive and hyperactive behavior of the child. The stimulant proposed to be used in this case is Adderall XR 40 mg daily.

3. Education of patients

There will be a need for the mother to be educated to ensure that the child is well informed of the need for adherence to the use of medication. The child should not underuse or overuse medication and should report any side effects suffered by the child.

4. Referrals

The child may be referred to a counselor who will help in the provision of therapeutic help.

 

                        

Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options, and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment.

References

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of internal medicine170(7), ITC49-ITC64.

Rubia, K. (2018). Cognitive neuroscience of attention deficit hyperactivity disorder (ADHD) and its clinical translation. Frontiers in human neuroscience12, 100.

Schramm, E., Klein, D. N., Elsaesser, M., Furukawa, T. A., & Domschke, K. (2020). Review of dysthymia and persistent depressive disorder: history, correlates, and clinical implications. The Lancet Psychiatry7(9), 801-812.

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