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Patient Information:
Medical/ surgical history: Recent in-patient stay at The Village Behavioral Health Facility for
Birth History: Step-mother reported mother had a vaginal delivery at forty weeks to her
requested. Step-mother is unsure if mother took prenatal vitamins. C. G. was bottle fed for the
first full year, step-mother is unsure of which formula was used. Birth weight was eight pounds
two ounces. Step-mother is unsure about group B strep. No reports of gestational diabetes
mellitus, hypertension, or pre-eclampsia. Step-mother reports mother did not use tobacco or
alcohol during pregnancy nor was it allowed in the home after birth. Step-mother reports the
home is alcohol and tobacco free. APGAR score is unknown. Step-mother reports mother was a
G1 P1 A0. C. G. was diagnosed with depression a “few months ago.” Step-mother states all
Family/Social: C. G. was recently expelled from the public-school system for presenting to
school with a weapon. Currently, C. G. is being home schooled. Step-mother reports a recent
change in social interaction. Step-mother reports C. G. will be calm and attentive then
“immediately starts pacing and rubbing his head.” C. G. does attend Sunday School. However,
met and later married C. G.’s father when he was seven. C. G.’s father has full custody. C. G.’s
step-mother reports they live in a single family one level ranch style home that was built in 2000,
and the home was built energy efficient. C. G.’s step-mother feels the home is located in a
“good” area of Hamblen County and feels as if it is a safe place to raise C. G. C. G. does not
have a brother or sister. C. G. had one pet (a cat) that died three months ago of natural causes.
This was a traumatic event for C. G. as he was the one who found the cat, the cat was C. G.’s
“best friend.” C.G.’s step-mother reports both maternal and paternal grandparents live close they
are without medical disparities and have an active part in C. G.’s life. C. G. does have a
biological uncle that lives in another state which he sees annually. C. G. has a step-aunt and
Accompanying adult: Step-mother who serves as a primary care provider for C. G. she is not
(S)ubjective Data
CC: Well Visit
Nutritional Assessment: C. G. eats three meals a day along with two to three snacks. C. G.’s
step-mother reports he is a very healthy eater. Breakfast consists of free range eggs; two
scrambled with two pieces of whole wheat toast and some type of berry jelly with orange or
apple juice and milk. Mid-morning snack is some type of fresh fruit. Lunch is a protein and two
vegetables such as a grilled chicken breast, green beans and a baked potato or an oven roasted
turkey sandwich with cheese, lettuce, tomato and mayonnaise with baked plain chips and 100%
fruit juice. Afternoon snack is typically cheese or peanut butter and crackers. Dinner is a protein,
starch and a green vegetable or salad with juice or milk. C. G. has a snack before bed which
consists of a bowl of cereal, Cheerios or Corn Flakes, or string cheese, fresh fruit or yogurt and a
glass of milk.
Elimination patterns: C. G. reports daily bowel movements later in the evenings, reports stool
Sleep hygiene & patterns: Step-mother and patient reports difficulty sleeping “rambles” during
the night sleeps in approximately four-hour intervals. C. G. takes daily showers and brushes his
very concerned with the patient’s behavior and aggression toward her. C. G. expresses a fear of
“doing the job” if he had “something sharp.” When ask to elaborate C.G. stated he was afraid he
romantic relationships, expresses frustration with parents when they disagree with C. G.’s
thoughts and wishes. Reports no close friends identifies his cat was his best friend.
Dental visit/vision test: Step-mother reports both dental and vision tests are up-date she reports
Social interaction: Home, school, family C. G. is currently home schooled and has no close
friends. C. G. interacts mostly with his parents and step-mother. Step-mom reports minimal
Review of Systems:
Sleep: Step-mother and patient reports difficulty sleeping “rambles” during the night sleeps in
Diet: Regular diet no issues or concerns reported. Step-mother reports overall healthy diet with
Behavior / activity: Step-mother reports isolated behavior with lack of desire to befriend others.
Eyes: No reports of blurry or double vision, no reports of sensitivity to light, floaters, itchy,
pressure.
Throat: No reports of changes in voice, sore throat, dysphagia, loss of teeth or change in taste.
GI: No reports of dysphagia, nausea, vomiting, diarrhea, cramping, daily BM without difficulty.
Endocrine: No reports of heat or cold intolerance, goiter, polyphagia, polydipsia, dry hair or
skin.
MS: Denies joint stiffness, muscle cramps, or swelling. No reports of difficulty with ROM or
ambulation.
Neuro: No reports of headache, seizures, loss of vision, hearing, speech, syncope or vertigo.
During adolescence, young people are expected to develop their sexual identity. This is gained
through the discovery of oneself and in the course of finding meaning to their personhood. They
may also experience identity crisis as a result of the transition from childhood to adulthood.
Some adolescents may feel confused and are unsure whether an activity is age-appropriate for
them. Crisis at this stage may also be brought about by expectations from themselves and from
This stage of Erickson’s theory has not been met at this point as C. G. does not express a sense of
self. C. G.’s social interactions and social skills are impaired at this point in his life. He was
expelled from public school for bringing a weapon and does not have friends; his cat was his
“best friend.” C. G.’s step-mother denies awareness of the apparent issues with C. G. until this
office visit. C. G. is very insecure and unsure of where he fit’s in in today’s society.
Appropriate or delayed
erect in a chair. Dressed appropriate for age and weather. Cooperative made minimal eye contact
and interacted appropriately during physical exam. No guarding fidgeting or grimacing noted.
Actively participated in answering questions at the beginning C. G.’s demeanor changed when
questioned about his social interaction. C. G. expressed the desire to do self-harm if given the
opportunity.
Eyes: PERRLA 2 and brisk red reflex. Sclera white, pale yellow crust and periorbital erythema
noted.
Ears: Bilateral tympanic membranes visualized, pearly grey no redness or bulging noted.
Nose: Nares patent bilateral without septal deviation. No polyps or bogginess. Frontal, maxillary,
ethmoid, and sphenoid sinuses without tenderness. Clear secretion bilateral nares.
Buccal mucosa, tongue, and gums pink and moist. Hard and soft palate without deformity.
Skin: Pink, warm, dry, intact without rash, ecchymosis or edema. Old scaring noted to left upper
Respiratory: Respiratory rate even and unlabored resonant throughout no wheezing, crackles,
quadrants. No abdominal bruit noted. No reports of pain or tenderness with light and deep
MS: Full ROM to all joints no swelling or redness. Cervical spine with full extension, flexion,
and rotation. Thoracic, lumbar spine full ROM forward bend and toe touch without difficulty. No
Neuro: Alert, oriented times four. Cranial nerves are intact. Limbs symmetrical without gait
Psych/behavior:
Other: C. G. presented in a clam, cooperative manner no issues identified during physical exam,
while questioning C. G. his demeanor changed he became anxious and stated pacing. C. G.
expressed the desire to do self-harm if given the opportunity. After a telephone interview with
(Assessment) Dx:
Rhinorrhea J34.89
Differential Diagnoses: (this includes any diagnoses which could be considered using the
above information)
1. Bipolar F31.3
3. Schizophrenia F20.9
(Plan)
Other: Due to the expression of suicidal ideation Mobil Crisis was consulted, and the patient
was transported to an in-patient facility where he will await placement at a psychiatric facility.
Always wear a safety helmet with elbow and knee pads when riding a bicycle, roller-
skating, or skateboarding.
Reviewed the need for daily exercise and limit time spend in front of the television and
Daily bathing or showers with brushing teeth twice a day and flossing at least once a day.
Discussed firearm safety with step-mother, instructed her to keep all firearms and any
Avoidance of soft drinks and increasing water intake. Eat 1200 kcal/day, at least two cups
of milk a day, three ounces of lean meat/day, one and a half cups of fruit/day, one cup of
discussed the fact there was no secrets between him, his parents and his provider. We
also talked about his home and the doctor office being “safe zones.”
Discussed the importance of spending time with C. G. doing thing he has interest in and
allowing him the opportunity to express himself as well as respecting his privacy.
Discussed the importance of avoiding substance abuse and avoiding individuals that
Discussed the importance of rules and respect for both the parents and C. G.
Discussed proper technique and time frames to brush teeth, floss and use mouthwash to
prevent dental caries. Along, with the avoidance of sugary drinks, candy, and foods.
COMPETENCIES
3 NONPF Competencies:
Critically analyzes data and evidence for improving advanced nursing practice.
Integrates knowledge from the humanities and sciences within the context of nursing services
Translates research and other forms of knowledge to improve practice processes and outcomes
This competency was met due the advanced knowledge learned through King University’s
Family Nurse Practitioner program signs and symptoms were taken into consideration along with
a detailed history and physical to reach a conclusive diagnosis. This patient may not have
2.Quality Competency
Evaluates the relationships among access, cost, quality, and safety and their influence on health
care.
Evidence based practice was utilized in the treatment plan for this particular patient as well
utilizing extended services available to meet the immediate needs of both the patient and
healthcare facility.
Provides the full spectrum of health care services to include health promotion, disease
abnormal findings.
Advanced assessment skills were utilized to diagnosis, treat and educate the step-mother as to the
current state of her step-son. Through advanced knowledge and assessment skills, this patient
https://www.cdc.gov/growthcharts/data/set2clinical/set2color.pdf
http://www.heart.org/HEARTORG/HealthyLiving/Dietary-Recommendations-for-
Healthy-Children_UCM_303886_Article.jsp#.WmJ-AzdG3IU
https://www.healthcare.gov/preventive-care-children/