ADHD

9.24 MWS

NR 546 Week 7 Case Study- Child and Adolescent

Subjective Objective

M.K.'s mother brings her in with concerns

about M.K.'s inability to focus, excessive

fidgeting, and impulsive behavior both at home

and in school.

Client’s Chief Complaints:

"M.K. is frequently disruptive in school and is

struggling academically. Her behavior has led

to failing grades, and the school has issued a

warning that she may face suspension if her

disruptive behavior continues." Additionally,

mother reports M.K. is not passing any of her

courses and fails to turn in homework

assignments she has completed.

History of Present Illness

M.K. has had difficulty concentrating and

staying seated in class since starting school. Her

teachers report that she often interrupts others,

is easily distracted, and has trouble completing

tasks. These symptoms have been persistent for

the past two years and have been affecting her

academic performance and social interactions.

Mother notes that M.K.'s academic performance

has significantly declined over the past school

year, despite her efforts to provide support and

encouragement at home. She reports that M.K.

often expresses frustration and self-doubt about

her abilities, leading to feelings of low self-

Physical Examination:

Physical Examination (Obtained by Pediatrician 2 Days

Earlier)

Vital Signs: Temperature 98.6°F, heart rate 90 bpm,

respiratory rate 18 bpm, blood pressure 110/70 mmHg.

General: Well-nourished, alert, and cooperative.

HEENT: Normocephalic, atraumatic, pupils equal, round,

and reactive to light, no ear discharge, throat clear.

Cardiovascular: Normal heart sounds S1, S2, no murmurs.

Respiratory: Clear breath sounds bilaterally, no wheezes or

crackles.

Abdomen: Soft, non-tender, no masses.

Musculoskeletal: Normal gait, full range of motion.

Neurological: Alert and oriented, normal reflexes and

muscle tone. CN II-XII intact

Skin: No lesions or edema

9.24 MWS

esteem and avoidance of school-related

activities.

M.K's disruptive behavior and academic

struggles have caused significant distress within

the family, impacting their daily routines and

interpersonal relationships. Mother expresses

concern about M.K.'s ability to succeed

academically and socially.

Past psychiatric history:

There is no previous psychiatric history. This is

the first time M.K. has been evaluated for

behavioral or mental health concerns.

Past Medical History:

M.K. is generally healthy with no significant

past medical issues. She has had the usual

childhood illnesses such as colds and ear

infections, but nothing requiring hospitalization.

Perinatal history:

M.K. was born full-term through a normal

vaginal delivery. There were no complications

during the pregnancy or delivery. Apgar scores

were normal.

Developmental:

Mother reports M.K. met all her developmental

milestones within normal timeframes. She

walked by 12 months and spoke in complete

sentences by 2 years of age. There have been no

concerns regarding her physical or cognitive

development.

Family History

• Father is alive and well diagnosed with

ADHD in childhood, not currently on

medication

• Mother is alive, has anxiety

• One brother, age 10, alive and well

Mental status exam:

Appearance: Well-nourished 9-year-old female who

appears to be stated age. She appears well-groomed and

appropriately dressed for the appointment.

Alertness and Orientation: Fully oriented to person‚ place‚

time‚ and situation, Alert

Behavior: M.K. demonstrates hyperactive and impulsive

behavior. She is restless, fidgets in her seat, frequently shifts

positions, and appears restless. She has difficulty remaining

seated for extended periods and often interrupts the examiner

with unrelated comments or questions.

Speech: M.K.’s speech is rapid and pressured, with a

tendency to talk excessively and impulsively. She frequently

interrupts the examiner and struggles to wait her turn during

conversations.

Mood: “happy” Mother reports generally good but becomes

frustrated easily.

Affect: Labile, with frequent shifts in emotional expression.

She displays exaggerated facial expressions and gestures,

reflecting her emotional dysregulation.

Impulse control: Poor. She was touching items on the

provider’s desk despite multiple reprimands from her

mother.

Thought content: Mother denies that M.K. makes any

comments about death, denying any preoccupation about

death to herself or others. The patient does not engage in

purposeful self-harm behaviors,

Perceptions: No evidence of psychosis, not responding to

internal stimuli

Memory: Remote memory appears fair. She can repeat three

objects immediately but not after 5 minutes.

Concentration: When focused, she is able to sing the ABCs

and count to 99. Otherwise, she has a very short attention

span and is distracted.

Attention and observed intellectual functioning:

Intelligence appears to be average.

9.24 MWS

Social History

M.K. lives with her mother and father in a

suburban neighborhood. She is in the third

grade and has a few close friends but struggles

with maintaining friendships due to her

impulsive behavior. M.K. enjoys drawing and

playing outside but often gets bored quickly

with activities.

Trauma history: No reports of trauma

Review of Systems

• General: No weight loss, fever, or

fatigue.

• HEENT: No vision or hearing

problems.

• Cardiovascular: No chest pain,

palpitations, or syncope.

• Respiratory: No shortness of breath or

chronic cough.

• Gastrointestinal: No abdominal pain,

nausea, or vomiting.

• Genitourinary: No dysuria or

hematuria.

• Musculoskeletal: No joint pain or

muscle weakness.

• Neurological: No seizures, headaches,

or loss of consciousness.

• Psychiatric: Difficulty concentrating,

hyperactivity, impulsivity, mood

swings. Sleeps 5-7 hours at night;

difficulty falling asleep

Allergies: NKDA

Fund of knowledge: Good general fund of knowledge and

vocabulary

Insight: Limited; does not fully understand the nature of her

difficulties.

Judgment: Age-appropriate but impulsive

Diagnosis: (F90.2) Attention-Deficit/Hyperactivity Disorder, Combined

Presentation