Please rewrite this case study below as the format attached. I need it as soon as you can and in the format attached. please add additional fluff, information to make it more scholarly.
Patient Information: BJ, 13-year-old, Caucasian male CC: â€œI hate schoolâ€HPI: BJ presents with his mother, who reports behavioral problems at home and school. According to his teachers, he is distracted, disruptive and forgetful. He has difficulty focusing, following directions and waiting his turn. His bag for school, desk, and locker are a mess. He is often unprepared for class and fails to complete homework assignments. When the teacher reminds him about the homework, he gets upset and snaps at her. He does not follow directions or complete his chores at home, especially when he is assigned more than one task at a time. Current Medications: NoneAllergies: NKDAPast Medical History Unremarkable, immunizations up-to-dateSocial History Full-time studentRecreational drug: denies Independent for ADLs Lives at home with mother
Parents recently divorced (one month ago), visits dad one weekend a monthNo known history of sexual or physical abuse or psychological traumaFamily HistoryPaternal: living, hx of cocaine abuse
ROSROS unremarkableEXAMVS: BP: 108/76 sitting, 104/68 standing, 80 pulse, regular, respirations: 16 temperature 98.2 SpO2: 99% weight: 120 lbs. height: 5â€ 4â€ BMI: 20.6OBJECTIVEPhysical exam unremarkable MSEAppearance: dress is appropriate for environment, situation, and stated ageBehavior/Activity: fidgety throughout consultationSpeech: spontaneous, coherent with appropriate volume, tone, and rateThought form: logical and goal directedThought content: no auditory hallucinations or delusions notedMood: euthymic Affect: irritable, improves as consultation progressesSuicidal Ideation: none Homicidal Ideation: none Orientation: A/O x 3Memory: immediate, recent, and remote memory intactJudgment/Insight: fairAttention/Concentration: distracted, does not focus on interviewer and requires questions be repeatedSCREEINGSMMSE: cognitive errors noted, spelled WORLD backwards and serial 7s incorrectDIAGNOSTICSUrine toxicology screen: negative
DIAGNOSISAttention-deficit hyperactivity disorder, predominantly inattentive type, F90.0BJ meets criteria for this diagnosis as evidenced by behaviors listed below, which are manifested both at school and at home:â€¢ Repeated thoughtless schoolwork mistakesâ€¢ Difficulty maintaining attentionâ€¢ Difficulty completing schoolworkâ€¢ Ineffective time managementâ€¢ Forgetfulness related to daily activities â€¢ Repeatedly loses essential school equipment (American Psychiatric Association, 2013)
PLANObtain baseline weight, BP, pulse, EKG, and Vanderbilt ADHD scaleHave parents and teachers complete Vanderbilt ADHD scale prior to each follow-up visitTutoring as neededDaily physical activity (at least 60 minutes)Refer for mindfulness therapyStart methylphenidate ER 18mg PO daily (Wolters Kluwer, 2019)EDUCATIONAs the nurse practitioner, I would provide the patient and family with education pertaining to the following:â€¢ Diagnosis â€¢ Medications â€¢ Monitoring for stimulant side effectsâ€¢ Vanderbilt ADHD scaleâ€¢ Importance of collaborative care, including teacher, father, and PMHNPâ€¢ Benefits of psychotherapy
REFERRALReferral to psychotherapist for mindfulness therapyFOLLOW-UPOne week or sooner for medication management and supportive therapy
ReferencesAmerican Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Publishing.
Wolters Kluwer. (2019). Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis. Retrieved August 11, 2019, from https://www.uptodate.com/contents/attention-deficit-hyperactivity-disorder-in-children-and-adolescents-overview-of-treatment-and-prognosis?search=adhd%20treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
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