Chronic disease: mild ADHD 8 years old patient, diagnosed w ADHD at 7 years old , with hyperactive/impulsive behavior, in office for treatment

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)

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