Assessing Clients Assignment Paper

Part 1: Comprehensive client family assessment

Demographic information

Patient Name: J.H..

Sex: Male

Date of birth: 11-17-07

Age: 11 years

Religion: Catholic – Christian

Legal Status: Minor – Dependent

Preferred Language: Major – Latino, Minor – English

Presenting problem

The patient is reported to have poor academic performance in his 5th grade school. The issue was first identified by his teacher who reported the same to his parents. Other than academic activities, the gym teacher also reports that the patient does not perform well in sports and social activities, always appearing as a loner. The parents and teachers concur that the patient has been generally inattentive by failing to pay close attention both at home and in school over the last one year. This is particularly seen when he spaces out during conversations and class activities. The patient reports that: “I dislike engaging in activities that have me thinking a lot or managing hard tasks Assessing Clients Assignment Paper.”

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History of present illness

Over the last one year, the patient has reported typical attention deficit hyperactivity disorder (ADHD) symptoms that include interrupting, fidgeting, excessive talking, and unable to sit still in certain situations. Smith (2012) and Wheeler (2014) both concur that these symptoms are typically reported in ADHD.

Past psychiatric history

The parents report that the patient has been of sound psychiatric health.

Medical history

The parents report that the patient was diagnosed with asthma three years ago. The asthma is controlled through the use of Advair inhaler 100/50 1 puff INH BID and Proventil inhaler two puffs INH prn.

Substance use history

Neither the parents nor the patient have any history of substance abuse.

Developmental history

The parents report that there have been no delays.

Family psychiatric history

No psychiatric conditions in the parents’ family history.

Psychosocial history

The patient is not sociable and tends to be a loner. However, his parents are very sociable and have him tag along for social activities involving the extended family members.

History of abuse/trauma

There is no history of abuse or trauma with the parents adding that they encourage the use of dialogue in solving problems. The patient has never been subjected to corporal or physical punishment.

Review of systems

General: No night sweats or fever.

Skin: Normal baldness pattern due to aging with no changes to the skin.

Head: No history of seizures, dizziness, trauma, headaches, or trauma.

Eyes: No field or vision changes, or glaucoma diagnosis.

Ears: No vertigo or tinnitus.

Nose: No running nose, facture history or epistaxis.

Mouth and Throat: No pain or sores.

Neck: No pain, goiter or masses.

Respiratory: No hemoptysis, sputum, wheezing, or cough.

Gatrointenstinal: No black stools, diarrhea, vomiting or nausea.

Genitourinary: No urination urgency or frequency, or dysuria.

Neurologic: No paresthesia, tingling or numbness.

Musculoskeletal: No joint or muscle pain.

Hematologic: No history of transfusion, anemia or bleeding disorder.

Emotional: No history of abnormal adjustments, depression, or psychiatric problems Assessing Clients Assignment Paper.

Physical assessment

Vital signs completed: 1:38

B/P: 126/73

Pulse: 66 BPM

RR: 17 BP

Temp: 37oC

Pulse Ox: 99%

Weight: 30 kg

General appearance: Oriented and alert with no acute distress.

Skin: No abnormal lesions or moles noted.

Neck: No masses.

Cardiovascular: Regular rhythm and rate, no gallops, rubs or murmurs.

Lungs: No crackles or wheezes.

Mental status exam

The patient was initially cooperative but lost interest towards the end of the interview.

Differential diagnosis

The patient suffers from ADHD given the presented symptoms and results of the assessment.

Case formulation

The patient is brought in to address the ADHD.

Treatment plan

The patient should be subjected to a long-acting medication to address the ADHD since they increase the probability of compliance, are confidential and convenient (Bray & Kehle, 2011). The first formulation is methylphenidates whereby four options are open for consideration. The first option is Ritalin LA that will be presented as 60 milligrams, formulated as soda and that acts for 10 hours. The second option is Focalin XR that is taken as 30 milligrams, formulated as soda and that acts for 12 hours. The third option is Concerta that is taken as 30 milligrams, formulated as soda and that acts for 12 hours. Finally, is the Dayana Patch that is presented as 30 mg and formulated as a transdermal patch (Shier et al., 2013) Assessing Clients Assignment Paper.

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The second formulation is amphetamines whereby two options are available. The first option is the Adderall XR that is provided once daily as 60 milligrams, acts for 10 to 12 hours and involves the immediate release of 50% of the drug with the sustained release of the remaining drug over time. The second option is the Vyvanse that is provided once daily as 70 milligrams, acts for 12 hours and is presented as a capsule of d-amphetamine and l-lysine that must be hydrolyzed to release the drug (Shier et al., 2013). In this respect, either of the six options can be used on the patient, depending on availability and convenience of the drugs. Still, the medications that have the longest duration of activity offer the best treatment alternative and should be administered in the morning of every day.

Other than the medication, the patient should be subjected to behavioral training to enable her develop close relationships, acquire social skills, reduce antisocial and undesirable behaviors, and gain social problem-solving skills (Katona, Cooper & Robertson, 2012).

Part 2: Family genogram

References

Bray, M. & Kehle, T. (2011). The Oxford handbook of school psychology. Oxford: Oxford University Press.

Katona, C., Cooper, C. & Robertson, M. (2012). Psychiatry at a glance (5th ed.). Hoboken, NJ: Wiley-Blackwell.

Shier, A., Reichenbacher, T., Ghuman, H. & Ghuman, J. (2013). Pharmacological treatment of attention deficit hyperactivity disorder in children and adolescents: clinical strategies. Journal of Central Nervous System Disease, 5, 1-17. doi: 10.4137/JCNSD.S6691

Smith, G. (2012). Psychological interventions in mental health nursing. Berkshire: Open University Press.

Wheeler, K. (Eds.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company Assessing Clients Assignment Paper.