Focused SOAP Note and Patient Case Presentation Comprehensive Nursing Paper Sample

Focused SOAP Note and Patient Case Presentation Comprehensive Nursing Paper Sample

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.(Focused SOAP Note and Patient Case Presentation Comprehensive Nursing Paper Sample)

Past Psychiatric History:

• General Statement: The client entered treatment at age 14 for ADHD.
• Caregivers (if applicable): Father(Focused SOAP Note and Patient Case Presentation Comprehensive Nursing Paper Sample)
• Hospitalizations: No previous hospitalizations.
• Medication trials: None.
• 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.(Focused SOAP Note and Patient Case Presentation Comprehensive Nursing Paper Sample)

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.
• 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.
• 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.(Focused SOAP Note and Patient Case Presentation Comprehensive Nursing Paper Sample)

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.
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).(Focused SOAP Note and Patient Case Presentation Comprehensive Nursing Paper Sample)

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).

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.(Focused SOAP Note and Patient Case Presentation Comprehensive Nursing Paper Sample)
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.(Focused SOAP Note and Patient Case Presentation Comprehensive Nursing Paper Sample)

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. (Focused SOAP Note and Patient Case Presentation Comprehensive Nursing Paper Sample)

References 

American Psychiatric Association (APA). (2019). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Publishing(Focused SOAP Note and Patient Case Presentation Comprehensive Nursing Paper Sample)

Ramsey, L. B., Bishop, J. R., & Strawn, J. R. (2019). Pharmacogenetics of treating pediatric anxiety and depression. Pharmacogenomics, 20(12), 867-870(Focused SOAP Note and Patient Case Presentation Comprehensive Nursing Paper Sample). 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)(Focused SOAP Note and Patient Case Presentation Comprehensive Nursing Paper Sample). https://doi.org/10.1002%2F14651858.CD012069.pub2