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Posted: December 20th, 2022
Patient is a 12 year old male with PPHx of ADHD,
NRNP_PRAC_6665_6675_FocusedSOAP
Patient is a 12-year-old male with a history of attention-deficit/hyperactivity disorder (ADHD) and disruptive mood dysregulation disorder (DMDD).
Attention-deficit/hyperactivity disorder is a mental health condition that is characterized by difficulty with attention, impulsivity, and hyperactivity. It is often treated with medications, such as stimulants, as well as with behavioral therapies.
Disruptive mood dysregulation disorder is a mental health condition that is characterized by chronic, severe irritability and frequent, intense temper outbursts. It is often treated with medications, such as mood stabilizers, as well as with behavioral therapies.
It is important for the patient to receive appropriate treatment for both of these conditions in order to manage his symptoms and improve his overall functioning. A mental health professional, such as a psychiatrist or psychologist, can work with the patient and his family to develop a treatment plan that is tailored to his needs. It is also important for the patient to receive support from his family and school, as well as to engage in self-care strategies, such as getting enough sleep and engaging in regular physical activity, to support his mental health.
Patient is a 12 year old male with PPHx of ADHD, DMDD, unspecified intellectual disability and multiple prior hospitalizations, who presents to crisis as transfer from Holtz for SI. Per BA, “patient ran away from home due to his parents finding tobacco products on him […] he was located and refused to go back to his house stating he wanted to go to crisis. He stated he does not feel like he should live anymore”.
Diagnosis *Complaint of Disruptive mood dysregulation disorder (ICD10-CM F34.81, Discharge, Medical) *Complaint of Unspecified mood [affective] disorder (ICD10-CM F39, Discharge, Medical) *Complaint of ADHD (ICD10-CM F90.9, Discharge, Medical)
Discharge plan Condition: Guarded. Admit: To Inpatient Unit. Suicide ideation: No. Homicide ideation: No. Psychiatrically stable: No. I have seen the CSSRS screening performed by the ED nurse and believe the patient has a low risk for suicide. -Admit to Inpatient, Involuntary and Incapacitated -Meds: -Psychotropic: ETOs only -Labs: COVID (pt recently admitted on 10/25) -Safety: No 1:1 sitter acutely indicated at this time. Continue current level of inpatient staff observation.
Discussed with team and will continue to monitor and treat as indicated. Upon interview patient is somnolent, dismissive, antagonistic and unwilling to cooperate with undersigned. He does endorse passive suicidal thoughts with no intent or plan and depressive symptoms including sad mood, anhedonia and poor energy levels. Regarding substance use, he endorses regular cannabis and alcohol use. He is unwilling to disclose reason why he was suspended from school.
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