NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation

Patient Details

Initials: T.P Age: 11 y/o Gender: Female Race:

Subjective:

CC (chief complaint): "I got into an argument with my mother and punched her on the

face since she took my phone for doing poorly in school work "

HPI: T.P. is an 11-year-old female who lives with her parents and two elder siblings, BIB

on 5585 for DTO. She has a history of ADHD and is in her father's company. It is reported that

she got into an argument with her mother and punched her in the face. The patient said that her

mother took her phone due to poor performance in school work. At the E.R., she was given

cocktail 5250. She presented to the clinic angrily, agitated, and combative. She had difficulty

sitting still, interrupted others, and did not wait for her turn. The patient also fidgets on her chair.

The patient complained of having a problem focusing on school. She feels like her mind wanders

off "a little bit" while in class. She does not like interacting with others at school but gets along

well with her sister and brother at home. She was diagnosed with ADHD years ago and took

Focalin and Ritalin, both effective. She stopped taking her ADHD medication due to a lack of

follow-up with the mental health provider. Minutes into the assessment, the patient appeared

sleepy, possibly from the cocktail shot she got in the E.R. The father reported that sometimes,

she gets easily annoyed or irritable several times, while some days she appears to be in a cheerful

mood, exhibiting hyperactivity. He stated that the patient has trouble finishing her duties and

tasks. She sometimes fails to complete her assignments which have gotten her in trouble with her

teachers and mother. The patient's father also reported that she has difficulty falling asleep at

night and instead stays up watching T.V. until about 3 am then sleeps until 6 am when she gets up

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric

Evaluation Template

to get ready for school. She has been taking Melatonin for insomnia, but that does not seem to

help. She denied hallucinations and delusions. She presented with DTO but no reports of self-

harm or suicidal ideations.

Past Psychiatric History: ADHD and insomnia

General statement: The patient presents to the clinic for the second time for

mental health evaluation due to ADHD symptoms.

Caregivers: Parents. He came to the clinic alongside his father

Hospitalizations: None

Medication trials: Focalin X.R. 15 mg once daily in the morning for ADHD and

Melatonin 3mg prn for insomnia

Psychotherapy or previous psychiatric diagnosis: ADHD and insomnia. No

psychiatric history.

Substance Current Use and History: The patient has no history of alcohol or any

substance abuse. She is still a minor, and substance use would indicate a poor upbringing.

Family Psychiatric/Substance Use History: Mother has a history of Diabetes. Father

has a history of ADHD, Bipolar Disorder, and Hypertension. Her elder sister and brother, 24 and

15, have no health concerns. Her father takes alcohol occasionally.

Psychosocial History: The patient lives with her parents and two elder siblings. She is in

the fifth grade and has a sister,24, and a brother, 15. She has a good relationship with her siblings

and parents. No sexual orientation issues. At times they cannot pick up the medications.

Medical History: No medical history

Current Medications: None