Adhd Case Study

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Recommended: Quizlet mental status examination

Identification: Dalton, Sharon 10 y/o African American female
Weight 110lbs, with NKDA.
Chief Compliant: Danger to self and Danger to others expressing suicidal ideations.
History: Patient is a 10 y/o female with past psychiatric history of MDD without psychotic features, IED, ADHD who was brought in by the police department on a 5150 hold for danger to self and danger to others. Per police report, Dalton Sharon called 911 and “stated her dad is hitting and choking her. When [Police} arrived, mom said she was upset because she wouldn’t go get cheeseburger for her.” The police report also notes that upon arrival, the patient had “destroyed her room and broke the bed. Made spontaneous statements that she did not want to live anymore.” In the emergency room, …show more content…

Mental Status Exam:
Vitals:
Blood Pressure: 112/59 ; Heart Rate: 100; Respirations: 15; Oxygen Saturation: 99% on room air; Temperature: 97.8; patient denies any pain or discomfort at this time.
Appearance: Young, well-nourished African American, appears stated age.
Interaction: Intermittently uncooperative
Eye Contact: Avoidant
Psychomotor: Reduced
Speech: Selectively mute
Mood: Appears tired and irritable
Affect: (Observed) Dysphoric, irritable, reported visual hallucination to nursing staff.
Thought Content: Patient reported desire to kill self
Thought Process: Blocking and guarded
Associations: Circumstantial
Orientation: alert and oriented X4
Memory: Adequate recent and remote history with no deficits.
General Knowledge: Adequate for age
Insight: poor
Judgment: poor
Intellectual function: Intact with normal abstract ability.

Family History:
Depression: Mother currently on Prozac 40mg daily.
Anxiety: Denies
Bipolar Disorder: MGM on Lithium
Schizophrenia: Denies
Suicidal attempts/Completion: Denies
Substance Abuse: Denies
ADHD: Brother

Substance Abusive History: Previous UDS (Neg)

Past Medical History: No pertinent past medical

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