Chronic disease: mild ADHD 8 years old patient, diagnosed w
ADHD at 7 years old , with hyperactive/impulsive behavior, in office for treatment
Case Presentation
For this activity, we will focus on presenting patients in addition to
assessing clinical reasoning. Students will select a patient from the clinical
setting that presents with a complaint consistent with the topical content for
the course week.
Presentations need to follow SOAP format with reflections. Address the
following:
1.
Subjective (S) =chief
complaint or reason patient presented for treatment with pertinent historical
information including PMH, Medication, Allergies, PSH, SH, and ROS.
2.
Objective (O) =exam
findings relevant to the chief complaint or reason for a visit including any
diagnostic tests [labs or imaging] done at the point of care.
3.
Assessment (A) = most
probable diagnosis includes at least 2 differential diagnoses for the acute
problem [new problem] and status of any chronic conditions listed in order of
priority.
4.
Plan (P) =include all
appropriate treatment as well as a written prescription and management of all
diagnoses addressed during the visit including patient education, health
promotion and disease prevention [age appropriate].
5.
Document the current CPT
billing codes for an office visit (level of service) and testing conducted
during the office visit.
6.
Reflections- what did
you learn, why did you pick this case, what would you do differently,
etc.
PowerPoint is limited to 5 slides [one for each item to
address, excluding title and reference slide].
Some available data:
Behavioral
• Immersive
behavioral therapy 25 hrs/ week ( preschool/ school aged children)
• Applied
behavior analysis
• Cognitive
behavior therapy
• Targeted
play/ Social skill training
• Parent
training
• Medical
• Tx of
anxiety, ADHD, sleep disorders
• Aripiprazole
(Abilify) and risperidone (Risperdal) only approved medications in the US for
ASD (irritability, aggression, self
injury)
• Side
effects: wt gain, sedation, tremor, extrapyramidal symptoms.
• Complementary
and alternative treatment
• Melatonin
(sleep, improves daytime behavior)
• Massage
therapy
• Therapeutic
horseback riding ( improvement in irritability and hyperactivity)
• Vitamin B
6 and magnesium ( improve behavior, speech and language)