Case Study

Posted: June 8th, 2023

Instructions

You will complete a comprehensive health assessment of a child/adolescent.

This should NOT be a patient you have encountered in your work but, instead, should be a family member or friend (who gives consent) or preferably a patient in clinical. You should note that all information will be confidential and that their private information will NOT be shared as part of this assignment.

Your assessment should be comprehensive, and you should refer to course texts to inform items for inclusion in your assessment. Keep in mind that you will be responsible for covering those areas addressed in the reading assignments up to this point. The documentation should remain HIPAA-compliant even though this is not a real patient. DO NOT USE REAL PATIENT IDENTIFIERS. Be sure to include birth and developmental information as well as school and behavior information for the child. Consider cultural, gender, ethnicity, spiritual, and social competencies needed to formulate the best care plan for the patient.

The patient will be referred to as Jane Doe or Jack Doe.

attachment
Instructions3.docx

Instructions

You will complete a comprehensive health assessment of a child/adolescent.

This should NOT be a patient you have encountered in your work but, instead, should be a family member or friend (who gives consent) or preferably a patient in clinical. You should note that all information will be confidential and that their private information will NOT be shared as part of this assignment.

Your assessment should be comprehensive, and you should refer to course texts to inform items for inclusion in your assessment. Keep in mind that you will be responsible for covering those areas addressed in the reading assignments up to this point. The documentation should remain HIPAA-compliant even though this is not a real patient. DO NOT USE REAL PATIENT IDENTIFIERS. Be sure to include birth and developmental information as well as school and behavior information for the child. Consider cultural, gender, ethnicity, spiritual, and social competencies needed to formulate the best care plan for the patient.

The patient will be referred to as Jane Doe or Jack Doe.

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Ratings

Pts

This criterion is linked to a Learning OutcomeSubjective Data

10 pts

Level 5

Includes all relevant subjective data neces

____________________________
Subjective Data for Jane Doe:

Name: Jane Doe
Age: 12 years old
Gender: Female
Ethnicity: Caucasian
Religion: None reported

Presenting Concern: Jane’s parents are concerned about her recent decrease in academic performance and her withdrawal from social activities. They have noticed changes in her behavior and want to understand if there are any underlying health issues contributing to these changes.

Medical History:
Jane has no significant medical history. She has been generally healthy and up to date with her immunizations. She has not experienced any major illnesses or hospitalizations.

Developmental History:
Prenatal: Jane’s mother reported a healthy pregnancy with no complications. She received regular prenatal care and took prenatal vitamins.
Birth: Jane was born full-term via vaginal delivery. Her birth weight was 7 pounds, 3 ounces, and she had no complications during birth.
Developmental Milestones: Jane met all her developmental milestones within the expected timeframe. She walked independently at 12 months, spoke her first words at 10 months, and achieved other developmental milestones on time.

Family History:
Jane’s family has no known significant medical conditions. Her parents and older sibling are healthy.

Allergies:
Jane does not have any known allergies to medications, foods, or environmental factors.

Social History:
Jane lives with her parents and older sibling in a suburban neighborhood. She attends a local public middle school. She is not involved in any extracurricular activities or sports at the moment. Her parents report that Jane used to enjoy spending time with her friends and participating in activities, but she has become increasingly withdrawn over the past few months.

School Performance:
According to her parents, Jane’s academic performance has declined recently. She used to be an engaged student who enjoyed learning and performed well academically. However, her grades have dropped, and she has received comments from her teachers about her decreased participation in class and lack of focus. Her parents are concerned about this sudden change.

Behavioral Changes:
In addition to the decline in academic performance, Jane’s parents have noticed other behavioral changes. She has become more irritable and easily frustrated. She spends more time alone in her room and avoids social interactions with her family and friends. Jane’s appetite has decreased, and she has lost some weight recently. Her parents have also observed changes in her sleep patterns, with Jane having difficulty falling asleep and frequently waking up during the night.

Psychosocial History:
Jane’s parents report no major life stressors or recent significant changes in the family dynamic. They describe a supportive and loving home environment.

Cultural Considerations:
Jane’s family does not report any specific cultural considerations or practices that may impact her health or care.

Jane’s parents are concerned about her recent decline in academic performance, behavioral changes, and withdrawal from social activities. They are seeking a comprehensive health assessment to identify any underlying physical or psychological factors contributing to these issues and to develop an appropriate care plan for Jane.