Subjective

Objective

The client is a 7-year-old male accompanied by his mother and 9-year-old brother.

Client’s Chief Complaints:

“My son has endless energy, he can’t sit still. When he plays, he is too rough with other kids.”

History of Present Illness

This clint was previously diagnosed with attention- deficit/hyperactivity disorder (ADHD). The school reports that he cannot stay seated, frequently calls out in class, is disorganized, cannot complete his assignments, and has been known to be disrespectful to adults. According to his mother, he is very impatient, distractable and impulsive. At age 3, the child was in the Head Start Program, and it was noted that he was demonstrating extreme 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 4, he was evaluated and diagnosed with ADHD, combined type. Medication was not prescribed at that time due to age.

Physical Examination:

Physical Examination (Obtained by Pediatrician 2 Days Earlier) Height 48″, weight: 65 lb, BMI: 23.9

Vital signs: B/P, 100/60; P, 78; R, 16; T, 98.4

General: Well-nourished 7-year-old male

HEENT: PERRLA, EOMI, vision is 20/20, and hearing acuity is unremarkable.

Neck: No masses

Pulmonary: No wheezing, rhonchi, or rales Cardiac: S1, S2

Abdomen: No distension, bowel sounds × 4 quadrants, no masses or hernias

Lymph nodes: No swelling Extremities: 2+ pulses bilaterally Skin: No lesions or edema Neuro: CN II-XII intact

Mental status exam:

Appearance: well-nourished 7-year-old male who appears stated age. He is casually attired in a striped collared shirt, jeans, and sneakers, appropriate for age and weather. Hygiene and grooming are good.

Past psychiatric history: previously diagnosed with attention-deficit/hyperactivity disorder (ADHD). No medications.

Past Medical History: healthy

Perinatal history: full term pregnancy, uneventful. NSVD. Breastfed x 5 months.

Developmental: mother reports client demonstrates age-appropriate gross and fine motor skills. He is able to dress and undress, can tie his shoes, colors within the lines; he can balance on one foot, catch a tennis ball, and ride a bicycle with training wheels.

Family History

•         Father is alive and well.

•         Mother is alive, has anxiety

•         One brother age 9, alive and well

Social History

•         Lives with parents and brother

•         1^st grader at local public school

•         does not have any friends

Trauma history: no reports of trauma

Review of Systems

•      appetite good, weight stable

•      sleeps 5-7 hours at night, difficulty falling asleep

Allergies: NKDA

Alertness and Orientation: fully oriented to person‚ place‚ time‚ and situation, Alert

Behavior: He separates easily from his mother and brother to come with interviewer. When he enters the office, he sits down in the chair, puts his hands on the desk and states, “Let’s get to work.” Initially, he stays seated with good posture, but after several minutes, he becomes hyperactive and cannot stay seated. Boundaries are poor, and he often grabs objects off the desk. He frequently interrupts.

Speech: Speech is spontaneous. At times, tone is loud. Rate is fast, and he talks excessively. He has a mild lisp and some age- appropriate articulation errors.

Mood: “happy” Affect: constricted Impulse control: Poor.

Thought content: Suicidal and/or homicidal ideations: Cannot be elicited when questioned

Perceptions: No evidence of psychosis, not responding to internal stimuli, reports auditory hallucinations.

Memory: .Memory: Remote memory appears fair. He is able to repeat three objects immediately but not after 5 minutes.

Concentration: When focused, he is able to sing the ABC’s and count to 99. Otherwise, he has a very short attention span and is distracted.

Attention and observed intellectual functioning: Intelligence appears to be average.

Fund of knowledge: Good general fund of knowledge and vocabulary

Musculoskeletal: normal gait and station