FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION, PART 1

Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.(Psychiatric SOAP Note Comprehensive SOAP Note Example)

For this Assignment, you will document information about a patient that you examined during the last three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.

case

This patient is a 14-year-old male came into the office with his father for medication management. Patient’s father reported patient is doing slight better with his medications. Patient reported difficulty to concentrate. Patient’s father agreed to increase patient’s Concerta to 27 mg. Patient reported procrastinates a lot as a result he’s failing in school. Patient said he goes to bed late and sometimes he would be on his cellphone. Patient agreed to turn his phone off at 10:00 and go to bed. His father must wake him up 2-3 times and he spend a long time in the toilet. As a result, patient is always late for his earlier class and he’s about to fail. Patient is feeling sad and depressed. He said he knew he must do better, but he does know how to start.(Psychiatric SOAP Note Comprehensive SOAP Note Example)

Patient used to be an honor hall student. He once was the presidential award in 5th grade. Patient denied any history of illicit drug use. He denied any history of physical or sexual abuse or bullying in school. Patient has no remarkable medical history. Patient denied A/V hallucinations. He expressed himself very well for his development age. His speech had normal tone and volume. He established good eye contact. His father was very encouraging.(Psychiatric SOAP Note Comprehensive SOAP Note Example)

Patient seems to have a good support system. Patient agreed to change course. He was instructed to use an alarm system when he goes in the shower to prevent him to spend too many times. Patient agreed to continue to take his medication as ordered.(Psychiatric SOAP Note Comprehensive SOAP Note Example)

Adjustment disorder with mixed anxiety and depressed mood, F43.23 (ICD-10) (Active) Attention-deficit hyperactivity disorder, predominantly hyperactive type, F90.1 (ICD-10) (Active) Instructions / Recommendations / Plan: 1) Patient is to take his medication as prescribe. Patient’s father agreed to increase patient’s Concerta to 27 mg, and to continue current dose of Prozac 10 mg daily for depression/Anxiety. 2) Patient is to turn off his phone at 10:00 pm before he goes to bed. 4) Patient is to use an alarm when he goes to the shower to get out on time to go to school.(Psychiatric SOAP Note Comprehensive SOAP Note Example)

Patient no medical history

1 month, or earlier if needed

Psychiatric SOAP Note Comprehensive SOAP Note Example

Focused SOAP Note and Patient Case Presentation, Part 1

CC (chief complaint): “I know I must do better, but I don’t know how to start.”  

HPI: TV is a 14-year-old male presenting for medication management accompanied by his father. The client’s father reported a slightly better response to medication. The client reported difficulty concentrating and procrastination. The latter causes his failure in school. The client reported sleeping late and spending the most time on his cell phone. The client reported being woken up 2 to 3 times, spending much time in the bathroom, is always late for his early class, and is projected to fail. The client reported feeling sad and depressed. Initially, the client was an honor hall student, having received a presidential award in 5^th grade. His father was very encouraging.(Psychiatric SOAP Note Comprehensive SOAP Note Example)

Past Psychiatric History:

• General Statement: The client entered treatment at age 14 for ADHD.
• Caregivers (if applicable): Father
• Hospitalizations: No previous hospitalizations.
• Medication trials: None.(Psychiatric SOAP Note Comprehensive SOAP Note Example)
• Psychotherapy or Previous Psychiatric Diagnosis: Diagnosed with ADHD

Substance Current Use and History: The client denied any history of illicit drug use.

Family Psychiatric/Substance Use History: Not reported.

Psychosocial History: The client seems to have a sound support system. He denied any history of physical or sexual abuse or bullying in school.(Psychiatric SOAP Note Comprehensive SOAP Note Example)

Medical History: The client has no remarkable medical history.

• Current Medications: Concerta to 27 mg for ADHD and Prozac 10 mg
• Allergies: NKFDA
• Reproductive Hx: NA

ROS:

• GENERAL: No weight loss, fever, or chills.
• HEENT: No visual impairment, hearing disability, nasal congestion, and sore throat
• SKIN: No skin rashes or itching.(Psychiatric SOAP Note Comprehensive SOAP Note Example)
• CARDIOVASCULAR: No discomfort or pain.
• RESPIRATORY: No breathing complications.
• GASTROINTESTINAL: No nausea, vomiting, or diarrhea.
• GENITOURINARY: No dysuria or haematuria.
• NEUROLOGICAL: No numbness, tingling in all extremities, or headache.
• MUSCULOSKELETAL: No muscle pain or stiffness. No joint pain.
• HEMATOLOGIC: No anemia, ease of bleeding, or bruising.
• LYMPHATICS: No enlarged nodes.(Psychiatric SOAP Note Comprehensive SOAP Note Example)
• ENDOCRINOLOGIC: No polyuria or polydipsia.

Physical exam: NA

Diagnostic results: NA

Assessment

Mental Status Examination: The client is well-dressed and oriented. The client expressed himself appropriately for his development age. He established good eye contact. The client denied auditory or visual hallucinations. The client’s speech has a normal tone and volume and is coherent. No suicide or homicide ideation was noted during the exam.(Psychiatric SOAP Note Comprehensive SOAP Note Example)

Differential Diagnoses:

1. Adjustment disorder with mixed Anxiety and depressed mood, F43.23 (ICD-10) (Active) – Adjustment disorder is characterized by emotional and behavioral symptoms towards marked stressors that occur during a three-month duration, interfering with normal function (American Psychiatric Association [APA], 2019). Symptoms include marked distress and impaired functioning in significant areas.(Psychiatric SOAP Note Comprehensive SOAP Note Example)
2. Attention-deficit hyperactivity disorder, predominantly hyperactive type, F90.1 (ICD-10) (Active) – Hyperactive ADHD is characterized by symptoms such as fidgeting, difficulty sitting still, climbing things, being of the go, excessive talk, difficulty taking turns, inability to undertake activities quietly, blurting out answers, and interrupting others (APA, 2019).
3. Major depressive disorder, 296.32 (F33.1) (Moderate recurrent episodes) – Major depressive disorder is characterized by depressed mood or loss of pleasure in activities associated with symptoms such as insomnia, worthlessness, psychomotor agitation, difficulty concentrating, fatigue, and thoughts of death (APA, 2019).(Psychiatric SOAP Note Comprehensive SOAP Note Example)

Case Formulation and Treatment Plan:

Pharmacotherapy

1. Continue the prescribed medication. Patient\’s father agreed to increase patient\’s Concerta to 27 mg and to continue the current dose of Prozac, 10 mg daily, for depression/Anxiety. Concerta is effective and well-tolerated for treating AHDH symptoms (Storebø et al., 2018). Prozac is well-tolerated and effective in treating anxiety and depression in the pediatric population (Ramsey et al., 2019).(Psychiatric SOAP Note Comprehensive SOAP Note Example)

Psychoeducation

1. Educate the patient on the need to follow the prescription.
2. The patient is to turn off his phone at 10:00 pm before bed.(Psychiatric SOAP Note Comprehensive SOAP Note Example)
3. The patient should use an alarm when he goes to the shower to get out on time for school.

RTC: After two weeks.

Reflections:

The client reports sadness and depression associated with learning difficulties. The client reports difficulty with concentration. Spend more time in the bathroom, toilet, and waking up. These show that the client has ADHD hyperactive type. Moreover, the client presents symptoms such as difficulty concentrating, conflicted nature, sadness, and depression, which suggest major depression. However, ADHD and Major depression are secondary diagnoses since the client’s symptoms are better explained by adjustment disorder.(Psychiatric SOAP Note Comprehensive SOAP Note Example)

Conclusion

Psychiatric evaluation is crucial in establishing and monitoring mental health conditions. In this case, the client’s primary diagnosis is Adjustment disorder, with comorbid ADHD and MDD. The client responds slightly well to treatment, and increasing the dosage strength will likely improve the response. Besides, social support from the father is central to achieving positive health outcomes.(Psychiatric SOAP Note Comprehensive SOAP Note Example)

References 

American Psychiatric Association (APA). (2019). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Publishing(Psychiatric SOAP Note Comprehensive SOAP Note Example)

Ramsey, L. B., Bishop, J. R., & Strawn, J. R. (2019). Pharmacogenetics of treating pediatric anxiety and depression. Pharmacogenomics, 20(12), 867-870. https://doi.org/10.2217/pgs-2019-0088

Storebø, O. J., Pedersen, N., Ramstad, E., Kielsholm, M. L., Nielsen, S. S., Krogh, H. B., … & Gluud, C. (2018). Methylphenidate for attention deficit hyperactivity disorder (ADHD) in children and adolescents–assessment of adverse events in non-randomized studies. Cochrane Database of Systematic Reviews, (5). https://doi.org/10.1002%2F14651858.CD012069.pub2