Focused SOAP Note and Patient Case Presentation
Instructions
Subjective:
CC (chief complaint): The patient’s mother complained that her daughter is displaying some abnormal behavior at home and the teachers also complained to the mother that she is very disruptive and barely finishes individual work in school
HPI: The patient is a 7-year-old African American female who was brought by her mother due to hyperactivity, lack of concentration, and impulsiveness that she noticed when she was 5, but the mother thought it was normal for her age because she was her first child. The mother rated her symptoms 7/10 on the rate of a scale of 1-10 (10 being the worst). He sometimes displays some aggression toward her younger brother and some mood swings. Also always plays too much without focusing on what she is doing. The teacher also mentioned that she barely finishes her work in school and sometimes her mind will not be in class.
Substance Current Use: The mother denies any substance use or secondhand use.
Past psychiatric history: Denies
Medication trials and current medications: None
Psychotherapy or previous psychiatric diagnosis: None
Family psychiatric history: The patient’s paternal cousin has ADHD. The mother has a history of post-partum depression. No suicide, or unknown death before 30 years old.
Medical History: None
Allergies: Amoxicilline
Reproductive Hx: N/A.
Psychosocial: The patient was born and raised in Canton Texas. She is currently in 2nd grade in a private school. She has one younger brother. Her parents have been married for 9 years. No emotional or physical trauma. She has a good relationship with her father. She likes playing with her tablet, playing with friends at school, and playing on the playground. She also likes riding a bicycle with friends and her brother.
ROS:
- GENERAL: No weakness, chills, or fever noted.
- HEENT: Patient denied any head injuries, Eyes: No eye pain problems. Ear: Denies earache. Nose: rhinorrhea reported. Throat: No sore throat.
- SKIN: Eczema noted
- CARDIOVASCULAR: No cardiac issue or chest pain noted
- RESPIRATORY: Denies any SOB or coughing
- GASTROINTESTINAL: No abdominal discomfort
- GENITOURINARY: No painful urination or flank pain was reported.
- NEUROLOGICAL: No instability movement, numbness, or paralysis noted
- MUSCULOSKELETAL: No broken bone or muscle soreness was reported.
- HEMATOLOGIC: No abnormal bleeding, anemia, or fatigue was reported
- LYMPHATICS: No lymph node enlargement.
- ENDOCRINOLOGIC: Denies any excessive urination or excessive sweating.
- PSYCHIATRIC: Mother reports hyperactivity, impulsiveness, aggression, and inability to focus.
Objective:
Diagnostic results: CBC, BMP
BP: 118/76, Pulse: 80, PSO2: 99%, Temp: 97.6 *F
Assessment:
Mental Status Examination: Pt. is a 7-year-old African American female who presented to the office with her mother due to her hyperactivity, impulsiveness, aggression, and lack of focus in school. The patient denies any nightmares at night or sleep problems. She was alert during the appointment but seemed hyperactive and unstable mind when asked some questions. Mother answers all the questions. She denies any suicidal thoughts and was not a good reliable historian for some questions due to her age.
Diagnosis/Diagnoses – include all mental health diagnoses and the ICD-10 codes for each. Be Specific with diagnosis. Example: Major depressive disorder, recurrent, moderate F33.1; General anxiety disorder F41.1
- At least three differentials with supporting evidence. List them from top priority to least priority.)
Reflection
Discuss what you learned and what you might do differently. Include a brief rationale for your treatment plan. You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses and treatment plan. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rule out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected.
(Hint: the documentation in subjective and objective should support your diagnosis according to DSM-V!) Also, include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Case Formulation and Treatment Plan:
References
You are required to include at least 5 evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses as well as the treatment plan. Be sure to use correct APA 7th edition formatting.
Solution
Subjective:
CC (chief complaint): CC (chief complaint): The patient’s mother complained about her daughter displaying some abnormal behavior at home and the teachers also complained to the mother that she is very disruptive and barely finishes individual work in school
HPI: The patient is a 7-year-old African American female who was brought by her mother due to hyperactivity, lack of concentration, and impulsiveness that she noticed when she was 5, but the mother thought it normal for her age because she was her first child. The mother rates her symptoms 7/10 on the rate of a scale of 1-10 (10 being the worst). He sometimes displays some aggression toward her younger brother and some mood swings. Also always plays too much without focusing on what she is doing. The teacher also mentioned that she barely finishes her work in school and sometimes her mind will not be in class.
Substance Current Use: The mother denies any substance use or secondhand use.
Past psychiatric history: Denies
Medication trials and current medications: None
Psychotherapy or previous psychiatric diagnosis: None
Family psychiatric history: The patient’s paternal cousin has ADHD. The mother has a history of post-partum depression. No suicide, or unknown death before 30 years old.
Medical History: None
Allergies: Amoxicilline
Reproductive Hx: N/A.
Psychosocial: The patient was born and raised in Canton Texas. She is currently in 2nd grade in a private school. She has one younger brother. Her parents have been married for 9 years. No emotional or physical trauma. She has a good relationship with her father. She likes playing with her tablet and playing with a friend at school and on the playground. She also likes riding a bicycle with friends and her brother.
ROS:
GENERAL: No weakness, chills, or fever noted.
HEENT: Patient denied any head injuries, Eyes: No eye pain problems. Ear: Denies earache. Nose: rhinorrhea reported. Throat: No sore throat.
SKIN: Eczema noted
CARDIOVASCULAR: No cardiac issue or chest pain noted
RESPIRATORY: Denies any SOB or coughing
GASTROINTESTINAL: No abdominal discomfort
GENITOURINARY: No painful urination or flank pain was reported.
NEUROLOGICAL: No instability movement, numbness, or paralysis noted
MUSCULOSKELETAL: No broken bone or muscle soreness was reported.
HEMATOLOGIC: No abnormal bleeding, anemia, or fatigue was reported
LYMPHATICS: No lymph node enlargement.
ENDOCRINOLOGIC: Denies any excessive urination or excessive sweating.
PSYCHIATRIC: Mother reports hyperactivity, impulsiveness, aggressiveness, and inability to focus.
Objective:
Diagnostic results: CBC, BMP
BP: 118/76, Pulse: 80, PSO2: 99%, Temp: 97.6 *F
Assessment:
Mental Status Examination: Pt. is a 7-year-old African American female who presented to the office with her mother due to her hyperactivity, impulsiveness, aggression, and lack of focus in school. The patient denies any nightmares at night or sleep problems. She was alert during the appointment but seemed hyperactive and unstable mind when asked some questions. Mother answers all the questions. She denies any suicidal thoughts and was not a good reliable historian for some questions due to her age.
Diagnosis/Diagnoses
The identified differential diagnoses for the pediatric patient based on the history and clinical manifestation are attention deficit and hyperactivity disorder, autism spectrum disorder, and intellectual disability.
Attention Deficit and Hyperactivity Disorder (F90.9)
The priority diagnosis for the patient is attention deficit and hyperactivity disorder (ADHD) based on her signs and symptoms as well as her family history. The signs and symptoms of ADHD include hyperactivity, impulsivity, and inattention (Krull, 2022). The above symptoms tend to affect a patient’s academic, social, cognitive, and behavioral functioning.
Since the patient was 5 years old she started showing some symptoms such as lack of attention, hyperactivity, lack of concentration, and lately aggression towards her brother. The patient’s family history also shows that the patient’s paternal cousin suffers from ADHD and nursing literature shows that the condition has a strong genetic component (American Psychiatric Association, 2013).
Autism Spectrum Disorder (F84.0)
Autism Spectrum Disorder is the second diagnosis which refers to a neurodevelopmental disorder whose significant symptoms are limited social interaction and communication and restricted repetitive behaviors, activities, and interests (Hodges et al., 2019). The patient’s subjective information shows that she is hyper and at the same time disruptive and engages in repetitive behavior.
Intellectual Disability (F79)
The third diagnosis intellectual disability. Intellectual disability involves poor mental abilities that touch on two functions which are intellectual functioning such as learning, judgment, and problem-solving while the second area is adaptive functioning which involves activities of daily life like communication and independent living (Heyman et al., 2021). The patient lacks focus in school and during the session, the mother answers all the questions which shows that the child has some deficits in mental ability.
Reflection
If I were to assess the child again, I would engage her in some activities to assess her concentration level, interests, and different abilities such as judgment skills. The rationale that led to the decision on the different diagnoses was based on the patient’s clinical manifestation and history of signs and symptoms. Some of the legal and ethical issues that would arise when dealing with the patient’s case would touch on the choice of the most effective and safe treatment plan considering that the patient is a minor.
It would be vital therefore to make decisions incorporating ethical principles to ensure the well-being of the child. Health promotion should emphasize the need for follow-up, especially on medical appointments for regular assessments and compliance with the treatment and management strategies adopted.
Case Formulation and Treatment Plan:
Based on a patient’s accurate diagnosis, the patient can be put on medication and therapy. Research shows that pediatric patients who are diagnosed with ADHD can highly benefit from a combination of therapy and medication, some of the drugs used include dexmethylphenidate, guanfacine, and dexamfetamine among others. According to Pheils and Ehret (2021), dexmethylphenidate is a stimulant of the central nervous system that works by increasing attention while at the same time reducing hyperactivity and impulsiveness.
The starting dose should be minimal with the physicians assessing the patient for side effects. For autism spectrum disorder, the patient can be put on behavioral therapy, school-based therapies, medication, and even nutritional therapy to manage the symptoms and improve the patient’s cognitive and social functioning. Intellectual disability is managed by the use of stimulant medications, occupation therapy, psychoeducation, and even speech therapy.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Heyman, M., Galligan, M. L., Salinas, G. B., Baker, E., Blacher, J., & Stavropoulos, K. (2021). Differential diagnosis of autism spectrum disorder, intellectual disability, and attention-deficit hyperactivity disorder (ADHD). Advances in Autism.
Hodges, H., Fealko, C., & Soares, N. (2020). Autism spectrum disorder: definition, epidemiology, causes, and clinical evaluation. Translational pediatrics, 9(Suppl 1), S55–S65. https://doi.org/10.21037/tp.2019.09.09
Krull, K. R. (2019). Attention deficit hyperactivity disorder in children and adolescents: Clinical features and diagnosis. UpToDate, Waltham MA. Accessed April, 29.
Pheils, J., & Ehret, M. J. (2021). Update on methylphenidate and dexmethylphenidate formulations for children with attention-deficit/hyperactivity disorder. American Journal of Health-System Pharmacy, 78(10), 840-849.