Week 1 SOAP Note ADHD
Week 1 SOAP Note ADHD
Week 1 SOAP Note ADHD
United State University
Primary Health of Acute Client/Families Across the Lifespan-Clinical Practicum
FNP: 594
Subjective
ID: Tony Gray, Age: 6 years, Race: Caucasian, Gender: Male, Date of Birth:
January 5, 2016.
CC: The mother of the six-year-old child says that her son’s conduct is strange since he is always moving and cannot focus on any one thing for a long period of time. Additionally, she has been told by thechilds teacher that the he is often disrupting classes and is unable to complete assignments.
HPI: In this case, the patient is a 6 -year-old Caucasian boy who has been experiencing increasing levels of irritability, hyperactivity, and impulsivity over the past month. It is not related to the child’s inability to comprehend instructions. Moreover, the child’s mother claims that the child is not truly defiant. His teacher had previously reported these symptoms three times, so his mother decided to take him to the hospital to be tested because she had tried talking to him and even punishing him, but he did not appear to improve his rebellious behavior. Mother also notes that the child has been experiencing these symptoms since he was two years old, and she initially felt it was due to a developmental milestone, but because the symptoms have persisted, she believes her son is experiencing a problem. My son has never been diagnosed with any chronological disorders.
Current Medications: There are currently no drugs prescribed for the youngster.
Allergies: Penicillin causes an allergic reaction in him. Her son has no other known allergies or sensitivities, as far as her mother is aware.
Past Medical History: When he was three years old, he contracted pneumonia, which was treated successfully as an in-patient. BCG, tetanus/diphtheria/pertussis, and measles vaccines, as well as influenza and pneumonia vaccines, were given to the children. His mother states that he has never had any meningitis and that he is healthy. His son have never been in a traumatic situation before.
Family History: No medical history of mental disease on either the mother’s or father’s side of the family.
Social History: Despite the fact that his parents have two other children, the youngster is the middle child in a large family. The oldest sister is a twelve-year-old girl who is free of physical or mental difficulties at this time. The father works as a computer technician, and the mother works as a nurse in the family business. The father smokes and occasionally drinks, although he is not a heavy drinker. The mother does not consume alcohol or smoke.
Constitutionals: The patient claims that he is not feeling hot or warm. The boy’s mother also disputes that he has lost many weight. She, on the other hand, complains of extreme impulsivity, hyperactivity, and inattention, which are not supported by a lack of understanding. He does not have any sleep problems.
Respiratory: He is not having any difficulties breathing, and he is not coughing or producing any phlegm.
HEET: There are no complaints of dry eyes, irritation, or pain from the boy. He is not afraid of bright lights. Neither hearing loss nor tinnitus has been reported, nor has he reported any sneezing. His nose is likewise clear, and there is no pain in the throat.
Cardiovascular: He is not experiencing any discomfort or pain in his chest.
Genitourinary: During peeing, the youngster claims that he does not experience any burning. Neither polyuria nor hematuria was present
Gastrointestinal: There has been no vomiting, dehydration, or diarrhea reported by the mother.
Musculoskeletal: He claims that he has no muscle soreness or rigidity.
Psychiatric: An abnormal lack of attention and hyperactivity have been reported by the child’s mother. There are no indications of depression or anxiety in him, according to her.
Neurologic: He reports having no headache, experiencing instability when walking, experiencing numbness, or experiencing changes in bladder or bladder control.
Lymphatic: Neither the mother nor the son claims to have experienced any unusual bleeding or exhaustion. There are no swollen nodes.
Allergic: Eczema or asthma are not mentioned in the family history, according to mom. No additional seasonal allergies have been mentioned by the narrator, as well.
Endocrine: No one in the family claims to suffer from polyuria or excessive water consumption (polydipsia). As for increased perspiration or heat intolerance, they reject this as well.
Objective
Both the boy’s appearance and his nutrition are excellent. Physiological data: Pulse rate: 90; respiration rate: 20; temp: 37°C; blood pressure is 110/70; weight is 25.4kg; height is 51 inches; BMI is 15.1. The child has a normal body weight.
HEENT: The head is normocephalic and atraumatic, and its contours are typical. Both pupils are equal in size, circular in shape, and responsive to light and adaptation. Extraocular muscles are still in place and functioning. No tenderness is felt while palpating the nasal sinus canals. The tympanic membrane is intact and is neither discharged nor irritated. I do not have any bad breath. In the neck, there are no exudates at all.
Psychiatric: A state of mind that is in harmony with the information being processed. Fast, yet suitable, answers. Groomed to the highest standards. Restless and fidgety. Inability to focus and maintain eye contact for an extended period of time.
Neurological: The patient’s cranial nerves and symmetrical reflexes are normal. Being aware of one’s surroundings, including time, space, other people, and the physical location of one’s own body. Motor, sensory, and focus deficits have not been found.
Differential Diagnosis
Combined presentation ADHD: ICD-10-CM-F90.2 As a result of the child meeting the DSM-5 criteria for ADHD, this is the most likely primary diagnosis (Liu et al., 2020). The patient reported signs of the mainly inattentive subtype of ADHD, including trouble paying attention to a specific task, issues organizing chores, careless blunders, losing staff frequently, and appearing as if he is not listening when someone speaks to him. Additionally, the neuropsychological test was carried to rule out the presence of any other cognitive problems, and the results validated the initial diagnosis of ADHD.
Oppositional defiant disorder: ICD-10-CM-F91.3. This is another differential diagnosis because it generally affects younger children; it is largely characterized by rebellious, disobedient, and disruptive behavior that does not provide delinquent behaviors or more intense kinds of hostile or dissocial behavior but does not exclude these (Liu et al., 2020). Interestingly, the patient did not show up with any symptoms at all. In addition to antagonistic behavior, his actions were not directed at a specific event.
Autism spectrum disorder: ICD-10-CM-F84.0. This is another likely disorder because the disorder is linked to brain evolution and affects how individuals perceive and interact with other people, producing difficulties with social interaction. (Liu et al., 2020). It was found, through the neuropsychological test, that the youngster is inattentive in every topic, not just one, therefore, ruling out autism disorder.
PLAN
Diagnostic lab
Complete blood count (CBC) to rule out the possibility of anemia due to iron deficiency
Lead level, thyroid tests are performed to rule out any other organic issues.
Administer the National Institute for Children’s Health Quality (NICHQ), EEG could be a viable option. A magnetic resonance imaging (MRI) scan may be used to rule out an organic diagnosis (Cash et al., 2017).
Treatment Plan
Children’s psychotherapy, as well as the mother’s cognitive behavior therapy and psycho-education, are all options within this umbrella of mental health care (Stoll et al., 2018). Methylphenidate HCL (Ritalin) is a first-line drug with a rapid onset and short duration.Children aged 6 years and up should begin by taking 5 mg before breakfast and 5 mg before lunch. Increase the dose by 5 to 10 mg monthly, up to a maximum of 60 mg per day (Cash et al., 2017). Incorporating an Omega-3 supplementation into one’s diet as an alternative treatment is also a viable option (Chang et al., 2020).
Health Promotion
The overall goal of ADHD therapy is to improve a child’s perception of competence and ability to perform. It is recommended that the mother attend a support group for parents of children who have ADHD in order to avoid feeling like an outlier in her situation, Online ADHD resources were also suggested, and the mother was given ADHD pamphlets. (Wong et al., 2019). When she takes medication, she should be aware of the possible adverse effects and be able to report them immediately if they arise (Lankford & Silva, 2021). She should speak with her son’s instructors at school and inform them about the illness that he is suffering from, as well as the fact that he is receiving medicine and counseling.
Follow-Up
An evaluation of the medication and therapy regimen will take place after four weeks.
Constititional/Referral
Refer to a psychologist for a psychological evaluation of IQ, social/emotional adjustment, and learning impairments. Consult with the psychiatric specialist, to assist with medication coordination, Consult a school psychologist, if additional information is needed (Cash et al., 2017).
References
Cash, J., & Glass, C (2017). Family practice quideline (4th ed.). Springer Publishing Company, LLC.
Chang, J. G., Cimino, F. M., & Gossa, W. (2020). ADHD in children: common questions and answers. American family physician, 102(10), 592-602.
Lankford, A., & Silva, J. R. (2021). The timing of opportunities to prevent mass shootings: a study of mental health contacts, work and school problems, and firearms acquisition. International review of psychiatry, 33(7), 638-652.
Liu, L., Chen, W., Sun, L., Cheng, J., Su, Y., Rudaizky, D., … & Wang, Y. F. (2020). The characteristics and age effects of emotional lability in ADHD children with and without oppositional defiant disorder. Journal of attention disorders, 24(14), 2042-2053.
Stoll, K., Swift, E. M., Fairbrother, N., Nethery, E., & Janssen, P. (2018). A systematic review of nonpharmacological prenatal interventions for pregnancy‐specific anxiety and fear of childbirth. Birth, 45(1), 7-18.
Wong, I. Y., Hawes, D. J., & Dar-Nimrod, I. (2019). Illness representations among adolescents with attention deficit hyperactivity disorder: associations with quality of life, coping, and treatment adherence. Heliyon, 5(10), e02705.