Prac 6665 Week 3: Focused SOAP Note
Patient age and gender – 12; Male; Caucasian.
Disorder – ADHD.
Symptoms – Inattentiveness, impulsivity, anxiety, easily distracted, unable to finish tasks.
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? (Duration: 5 years, Severity: Moderate). How are their symptoms impacting their functioning in life? (Unable to focus in class and at home).
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.
Plan: What was your plan for psychotherapy? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also, be sure to include at least one health promotion activity and one patient education strategy.
Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be.
Include an introduction (with a clear statement of purpose) and a conclusion.
PRAC 6665 WEEK 3 ASSIGNMENT 2: FOCUSED SOAP NOTE SAMPLE SOLUTION
Focused SOAP Note
The Subjective, Objective, Assessment, and Plan (SOAP) is a widely used tool of documentation for clinicians. The tool reminds clinicians of particular tasks while providing an evaluation framework for clinical data. This SOAP note offers a cognitive approach for clinical reasoning, and guides the clinician in the assessment, diagnosis, and treating a 12 year old male child whose parent complains of abnormal levels of inattention, impulsivity, and hyperactivity.
MB, 12 yrs, Male, Caucasian
CC (chief complaint): The father to the 12 year old boy is that his son is been presenting abnormal tendencies characterized by inability to concentrate for long on tasks, is easily distracted, makes reckless mistakes when writing his school takeaway assignments, is relatively disorganized, and currently forgets and misplaces things. Also the father has received reports from the boy’s school teacher reports that he excessively disrupts fellow students, is restless, and does not complete class work assigned to him.
HPI (history of present illness): The 12-year-old male child is Caucasian with inattention, hyperactivity, and impulsivity that began 5 years ago and increasingly becoming pronounced. His clinical presentation is not related to a lack of capacity to understand instructions. Also, the father reports that the young boy is not uncooperative. The boy’s symptoms dissipate with reprimanding and occur at any time of the day. The father rates the symptoms, on ADHD’s scale of 1-10, at 6/10.
Current Medications: The patient is not on any medications
Allergies: Medication-Penicillin, Food-soy, Environmental- automobile smoke.
PMHx: Up to date on seasonal influenza (flu) (11/2020), shingles (2nd dose on 6th year birthday), and Td or Tdap vaccines & MMR vaccines (Date of tetanus injection, 11/2018; date of MMR second dose at 6 years of age). Successfully treated for pneumonia at age 5.
No history of meningitis, malaria, head injuries or any past major surgeries or illnesses,
Soc and Substance Hx: The patient resides in Arizona with his father and mother. He is the last born in a family of three with the elder siblings being female aged 18 and 15 with no mental or medical problems. The father is a police lieutenant and the mother is a medical record and health information technician. The parents have no history of smoking or alcohol consumption.
Fam Hx: Family history: No history of paternal or maternal mental illness in the family.
Mother – living healthily,
Father – living healthy.
2 sisters live healthy
Surgical Hx: No history of prior surgical procedures.
Mental Hx: Reports anxiety and but denies depression) Denies history of of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Denies history of concern or issues about safety (personal, home, community, sexual (current and historical).
ROS (review of symptoms):
General: Patient lean but appears healthy. Patient denies cold or heat intolerance. The father reports excessive impulsivity, hyperactivity and inattention not related with the lack of comprehension but denies any weight loss or sleep difficulties.
Head/Eyes: Denies eye pain, diplopia, blurred vision, or headache
ENT: Denies ear pain, sore throat, rhinorrhea or vertigo.
Cardiovascular: Denies chest pain, pressure, or palpitations
Respiratory: Denies cough, dyspnea, or shortness of breath
Gastrointestinal: Denies nausea, vomiting, diarrhea, constipation, heartburn, or abdominal pain
Genitourinary: Denies dysuria, incontinence, urinary frequency, hematuria
Musculoskeletal: Denies back pain or any recent trauma; reports muscle weakness, tingling, numbness or but denies pain in any other joints.
Neurological: Denies any changes in sight, smell, or hearing or taste; reports chronic weakness in his knees; denies transient paralysis, paresthesias, seizures, denies syncope, vertigo or tremors.
Psychiatric: Denies anxiety; denies depression, memory loss, mental disturbance, suicidal ideation, hallucinations, or paranoia
Endocrine: denies cold intolerance, heat intolerance, polyuria, polyphagia, polydipsia, polyuria
Heme/lymphatic: swollen lymph nodes, denies bruising, bleeding,
Psychiatric: Father reports the son has a history of hyperactivity and unusual lack of concentration. Parent denies noting any anxiety or depressive symptoms in the child.
Allergic/Immunologic: denies hay fever, urticaria, denies persistent infections.
VS: Temp 98.6; BP 115/73; HR: 90: RR 20; P 92; Weight 66lbs, HT 52.8 inches (child’s BMI is 16.7. That puts them in the 30th percentile which indicates that they are at a healthy weight), SpO2 95% on RA
General: The boy is alert, oriented x3, well-nourished and well-groomed.
HEENT: Head atraumatic and normocephalic with normal contours (NC/AT); PERRLA; extraocular muscles normal; external ears appeared normal, Nasal sinus passages non-tender on palpation, oropharynx clear with no lesions or erythema; Tympanic membrane normal, negative for redness or discharge; No halitosis; No throat exudates.
Respiratory: Bilaterally clear to auscultation, tactile fremitus normal, negative for egophony, respiratory effort normal
Cardiac: RRR, no murmurs, gallop or rub, normal S1/S2, rhythm normal; no thrill on palpation, no jugular vein distention, no point of maximal impulse displacement; no abdominal bruits or carotid; no enlargement of the abdominal aorta. Radial, carotid, pedal pulses 3+, and posterior tibialis symmetric, no edema.
Pulmonary: CTAB, CTA, chest wall symmetrical; non-tender and symmetrical joints; no erythema, clubbing, cyanosis, or edema. +2 peripheral pulses.
Abdominal: soft, normoactive bowel sounds, negative for rebound, negative sonographic Murphy’s sign, negative for McBurney; non-tender, soft, and non-distended abdomen with no masses; normal bowel sounds; liver size appears within normal limits; no liver masses or nodularity, no splenomegaly
Lymph Nodes: Negative for lymphadenopathy
Skin: No rashes, good turgor, membranes pink and moist
Neurologic: intact cranial nerves II-XII, symmetric reflexes normal; sensation normal, cerebellar function normal. Symmetrical DTR 2+; Alert and oriented in time, space, person, and place (AAOx3). Negative for sensory, motor, or focal deficits.
Mental Status Exam: Insight and judgment intact; AAOx3; memory for remote and recent events intact; no depression, agitation; negative for anxiety; Hasty but appropriate responses; mood congruent with content; properly groomed; unable to sustain eye contact and concentrate longer; Restless and fidgety.
(i) The patient satisfied DSM-5 criteria 1 and 2 for hyperactivity together with impulsivity and inattention (APA, 2013).
(ii) The blood levels of lead metal eliminated lead poisoning possibility, which induces similar symptoms (cite).
(iii) SNAP-IV (Swanson, Nolan, and Pelham version-IV) Scale Teacher Form was used to confirm ADHD (Markowitz et al., 2020).
(iv) A full blood count was used to eliminate the possibility of systemic infections (Nestor et al., 2020).
- F90.2 ADHD (Attention-deficit hyperactivity disorder combined type F90.2) is the first and very likely diagnosis motorized by developmentally improper levels of inattention, impulsivity, and hyperactivity (APA, 2013). The child presents over six symptoms of ADHD according to DSM-5.
- Autism spectrum disorder is the second likely diagnosis characterized by symptoms like making inconsistent or little eye contact, avoiding listening to all looking at people, hyperactive behaviour, marked deficits in nonverbal and verbal social communication skills, and abnormal or reduced responses to social overtures from others (APA, 2013).
- Oppositional defiant disorder characterized by behavioral and emotional symptoms lasting at least six months like angry and irritable mood, argumentative and defiant behaviour, and vindictiveness (APA, 2013; Belanger et al., 2018).
- Stimulant medications beginning with focalin (methylphenidate) 2.5 mg b.i.d (Stahl, 2017).
- Behavioral therapy for the boy and the parents involving psychoeducation, Cognitive Behavioral Therapy, and training in social skills (Magnus et al., 2018).
- Recommended alternative therapies include omega-3 vitamin supplementation and a healthy and balanced diet (NHS, 2021).
The parents should engage with other parents or guardians of ADHD children for social support. The parents should also be acquainted with the focalin side effects like nervousness and insomnia such that they can report promptly when the side effects surface. The parents should engage with the child’s teachers at school and from them of the child’s diagnosis, medication, and therapy.
Follow-up shall be done four weeks followed diagnosis and commencement of treatment, to assess the child’s response to therapy.
Clinicians can diagnose ADHD in children after a child has presented six or additional specific symptoms of hyperactivity or inattention on a regular basis for over 6 months in at least two settings (in the patient’s case, school and home). The physician can evaluate how the child’s behaviour relates with the behavior of other children of his or her age. This is because ADHD could be difficult to diagnose because of its relation in similarity to other conditions ASD and ODD. Because of the possible lasting implications of ADHD on children, supportive behavioral therapy is an important part of managing the child’s condition while also involving parents.
SOAP notes are vital tools that assemble information about a patient’s health status as well as communicate the information across healthcare professionals. The documentation structure of soap notes facilitates cognitive reasoning and information retrieval for learning from records. SOAP notes organise information in easy to locate places that is easy for clinicians to follow.
American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Author.
Bélanger, S. A., Andrews, D., Gray, C., & Korczak, D. (2018). ADHD in children and youth: Part 1-Etiology, diagnosis, and comorbidity. Paediatrics & child health, 23(7), 447–453. https://doi.org/10.1093/pch/pxy109
Magnus W, Nazir S, Anilkumar AC, et al. (2021). Attention Deficit Hyperactivity Disorder. In: StatPearls [Internet]. StatPearls Publishing; https://www.ncbi.nlm.nih.gov/books/NBK441838/
Markowitz, J. T., Oberdhan, D., Ciesluk, A., Rams, A., & Wigal, S. B. (2020). Review of Clinical Outcome Assessments in Pediatric Attention-Deficit/Hyperactivity Disorder. Neuropsychiatric disease and treatment, 16, 1619–1643. https://doi.org/10.2147/NDT.S248685
Nestor, D., Andersson, H., Kihlberg, P. et al. (2021). Early prediction of blood stream infection in a prospectively collected cohort. BMC Infect Dis 21, 316 (2021). https://doi.org/10.1186/s12879-021-05990-3
NHS (May 30, 2021). Attention-deficit/ hyperactivity disorder (ADHD). https://www.nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/
Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. Cambridge University Press.