Focused SOAP Note and Patient Case Presentation: NRNP 6665 week 9

Focused SOAP Note and Patient Case Presentation: NRNP 6665 week 9

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).

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