Focused SOAP Psychiatric Evaluation Comprehensive Nursing Paper Sample

Focused SOAP Psychiatric Evaluation Comprehensive Nursing Paper Sample

SUBJECTIVE:

Chief Complaint (CC):

Per the patient’s Mom. “I brought AB here because of his behavior in school, always getting in trouble.”

HISTORY OF PRESENT ILLNESS:

AB is an 8-year-old boy brought in by his Mom with the complaint of violent outbursts. According to his Mom, he’s always getting into trouble in school, and he breaks stuff when he’s angry. She further stated, “He doesn’t sit still and is easily distracted.” Symptoms were first noticed when the patient was about five years old, and his maternal grandmother observed that patient was exhibiting extreme tantrums. He would get overly angry when he was corrected, or his toy was taken away from him. However, symptoms became more noticeable after losing his two grandpas in 2020 and 2021.(Focused SOAP Psychiatric Evaluation Comprehensive Nursing Paper Sample)

 Mom further stated, she gets calls from the school about AB getting in trouble, and he’s “always the aggressor.” He fights his classmates and threatens he’ll kill them. He used to have good grades, but his grades are not so good anymore”. AB was asked what aggravates him, he responded, “I don’t know.” He denied any plan or intent to kill. His pediatrician saw him three weeks before his visit, and he was prescribed methylphenidate 10 mg PO QAM and referred him to a Psychiatric for further evaluation.  (Focused SOAP Psychiatric Evaluation Comprehensive Nursing Paper Sample)

MEDICAL HISTORY:

Asthma takes Albuterol as needed. AB is an 8-year-old boy brought to the clinic by his Mom for psychiatric evaluation following the complaint of his aggressive behavior and frequently getting in trouble in school. He has dressed appropriately for the time of year and did not appear to be in any apparent distress. His Mom was the primary informant, as patient responses were restricted. The patient was seated next to his Mom, was fidgety, distracted, and maintained poor eye contact. He denied any S/H ideations, A/V hallucination, and paranoia.(Focused SOAP Psychiatric Evaluation Comprehensive Nursing Paper Sample)

His sleep and appetite are good, and no noticeable weight changes were reported. Discussed Psychotherapy and the benefits of combined therapy with his Mom, and she agreed with the plan.(Focused SOAP Psychiatric Evaluation Comprehensive Nursing Paper Sample)

However, she stated she wouldn’t want to “keep him on medication for so long.” The benefits and side effects of methylphenidate were discussed, and the Mom advised that it would take up to 4 to 6 weeks for full effects of the medication to be noticed; all questions were answered(Focused SOAP Psychiatric Evaluation Comprehensive Nursing Paper Sample)

Substance Use History:

Being a minor, the patient’s mother does report the child taking any illicit substance. The mother reports they take caffeine, especially during winters on the family table, as ‘it adds some warmth.’

Current Medications:

For the last three weeks, the patient has been on methylphenidate 10 mg PO QAM that the primary care pediatrician prescribed and referred him to a psychiatrist for further evaluation.  (Focused SOAP Psychiatric Evaluation Comprehensive Nursing Paper Sample)

Allergies:No known allergies to medicines or food.

Reproductive Hx:

Not conducted as CC and HPI were noncontributory.

Review of Systems (ROS):

GENERAL: No fatigue, obesity, or unexplained fevers. No unusual weight changes were reported.

HEENT: Denies headaches, no head concussions, no unusual head shape. No apparent vision difficulties. Denies ear pain, no ear discharge, and no apparent hearing problems. No mouth breathing, no nasal congestion, nose bleeds or snoring, and hoarseness of the voice.(Focused SOAP Psychiatric Evaluation Comprehensive Nursing Paper Sample)

THROAT: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain or poor exercise tolerance.

RESPIRATORY: No chronic cough, no shortness of breath, and no exposure to tobacco smoke.

GASTROINTESTINAL: No constipation, diarrhea, nausea, or vomiting.

GENITOURINARY: Has normal frequency urination, reports no pain during urination, no blood in the urine.

NEUROLOGICAL: No dizziness, fainting, or headaches. Demonstrates signs of deficiencies in punishment processing, reward processing, and cognitive control.(Focused SOAP Psychiatric Evaluation Comprehensive Nursing Paper Sample)

MUSCULOSKELETAL: No muscle weakness, n joint swelling, no joint or limb pain.

HEMATOLOGIC: No excessive bleeding, no bruising

LYMPHATICS: No swelling of lymph nodes(Focused SOAP Psychiatric Evaluation Comprehensive Nursing Paper Sample)

ENDOCRINOLOGIC: No frequent urination

OBJECTIVE:

Diagnostic results:

Electroencephalography (EEG) signals indicated little electric explosions like spikes common in Epilepsy, although the child was not amid a clinical seizure (Cabral et al., 2020).

ASSESSMENT:

Mental Status Examination:

AB is an African American boy who looks his stated age. There were challenges in structuring the interview because the child had marked signs of hyperactivity and distractibility. In general, the child was fidgety, could not sit or stand still, and actively ran around the office. The child was cooperative sometimes. The mother’s report/ interview collaborated with those of the school teachers.(Focused SOAP Psychiatric Evaluation Comprehensive Nursing Paper Sample)

The child’s mood was euphoric and labile. Mood was moderately inappropriate and incongruent. AB had alexithymia. Speech was spontaneous, fluctuating tone and volume, and moderately fast. Thought derailment was evident and incoherent for his age. Although the boy denies harboring or verbalizing homicidal ideations, both parents and teachers report he threatens to kill those who get in the way.(Focused SOAP Psychiatric Evaluation Comprehensive Nursing Paper Sample)

Diagnostic Impression: Differential Diagnosis

1. F909 |Attention-deficit hyperactivity disorder, unspecified type-Confirmed

AB symptoms meet the diagnostic criteria for ADHD  premised on the mother report, parent and teacher behavioral rating scales, neuropsychological assessment clinical observations, and the EEG results. According to Emser et al. (2018), ADHD can be confirmed through a combination of age-inappropriate levels of inattention, impulsive behavior, and hyperactivity. The symptoms have continuously appeared before the age of twelve, lasted more than six months, and occurred in more than one home and school setting. While it is a medical fact that ADHD symptoms overlap with hose bipolar disorder like talkativeness, difficulty maintaining inattention, and distractibility, amongst others, ADHD was confirmed because of its early onset, depressive episodes are absent, and the symptoms were cyclic. These factors confirmed ADHD diagnosis.(Focused SOAP Psychiatric Evaluation Comprehensive Nursing Paper Sample)

• F913 |Oppositional defiant disorder- Confirmed

The patient was also diagnosed with ODD because of frequent temper tantrums, arguing with adults, and refusing to do what these adults have told him. He also gets easily annoyed by others and deliberately does things to upset others. He also tends to blame other children for his misbehaviors (Ghosh et al., 2017). Verbalizing the intention to kill others is a sign of vindictiveness primarily characterized in ODD; hence it was diagnosed as comorbidity.(Focused SOAP Psychiatric Evaluation Comprehensive Nursing Paper Sample)

• Bipolar Disorder – Refuted

Symptoms of BP include reduced need for sleep, racing thoughts, and accelerated speech. However, the mother does not report the child’s withdrawal from family and friends; hence, it refutes BP diagnosis (Kitsume et al., 2016).

• Intermittent Explosive Disorder (IED)-Refuted

IED has symptoms similar to either ADHD or ODD, like irritability, rage, and increased energy. However, in the case of AB, it was ruled out because of the absence of tremors and no verbal or physical aggression towards things or physical aggression towards things and animals. Shao et al. (2019) also note there is a need for the provider to rule out other causes like physical head injuries, which were absent.(Focused SOAP Psychiatric Evaluation Comprehensive Nursing Paper Sample)

PLAN:

Case Formulation and Treatment Plan

ADHD and ODD are co-occurring disruptive behavior disorders common in children. The best treatment and management approach is a multimodal approach that balances medication and non-medication interventions. Newcorn et al. (2020) posit that Guanfacine extended-release of 1mg PO daily. This amount can be increased to reach a maintenance dose of 4mg daily ER daily.(Focused SOAP Psychiatric Evaluation Comprehensive Nursing Paper Sample)

Non-Medication Interventions

To improve the chances of the effectiveness of medications or reduce dependency on drugs, family-based interventions are also recommended together with psychotherapy.  The first is parent training. Here, AB’s parents are helped to develop parenting skills that are consistent, positive, and less frustrating to both the child and the other family members. Everyone in the family develops shared goals on how to handle emerging problems. It is also essential to involve other authority figures like teachers. During parent-child interaction therapy (PCIT), the therapist trains the parent to best interact with their child. Psychotherapy interventions like cognitive problem-solving therapy are also incorporated to help the child identify and change thought patterns that lead to behavior problems. The parent education component will also include social skills training on interacting with peers positively and effectively.

Follow up with PCP as needed and for:

The child will be brought to the clinic for follow-up every 6-12 weeks during the first twelve months following the diagnosis. This is to keep track of whether the therapeutic interventions developed in the treatment plan are effective and confirm whether a change in the interventions is needed, particularly the need to discontinue medications.

Return to Clinic:

After six, the child will return to the clinic to review the efficacy of interventions initiated.

Reflections

Standard practice in treating and managing the symptoms of a child diagnosed with ADHD that co-occurs with ODD involves the prescribing of stimulant medication as first-line treatment. It is paramount that the diagnostic criteria conditions be met before initiating medicine. If I reencounter this child patient, I would also use standard protocols for assessment, titrate the medication dosage appropriately, and conduct routine monitoring. Most importantly, I would ensure all the significant stages of ADHD and ODD clinical pathways are adhered to. These pathways are referral, pre-assessment, assessment, diagnosis, and planning of the recommended treatment.  These steps would then be followed by initiating the treatment and continuing care during follow-ups and return to clinic visits.(Focused SOAP Psychiatric Evaluation Comprehensive Nursing Paper Sample)

References

Cabral, M. D. I., Liu, S., & Soares, N. (2020). Attention-deficit/hyperactivity disorder: diagnostic criteria, epidemiology, risk factors and evaluation in youth. Translational Pediatrics, 9(Suppl 1), S104.(Focused SOAP Psychiatric Evaluation Comprehensive Nursing Paper Sample)

Emser, T. S., Johnston, B. A., Steele, J. D., Kooij, S., Thorell, L., & Christiansen, H. (2018). Assessing ADHD symptoms in children and adults: evaluating the role of objective measures. Behavioral and Brain Functions, 14(1), 1-14.

Ghosh, A., Ray, A., & Basu, A. (2017). Oppositional defiant disorder: current insight. Psychology research and behavior management.

Kitsune, G. L., Kuntsi, J., Costello, H., Frangou, S., Hosang, G. M., McLoughlin, G., & Asherson, P. (2016). Delineating ADHD and bipolar disorder: a comparison of clinical profiles in adult women. Journal of affective disorders, 192, 125-133.(Focused SOAP Psychiatric Evaluation Comprehensive Nursing Paper Sample)

Newcorn, J. H., Huss, M., Connor, D. F., Hervás, A., Werner-Kiechle, T., & Robertson, B. (2020). Efficacy of guanfacine extended-release in children and adolescents with attention-deficit/hyperactivity disorder and comorbid oppositional defiant disorder. Journal of Developmental & Behavioral Pediatrics, 41(7), 565-570.(Focused SOAP Psychiatric Evaluation Comprehensive Nursing Paper Sample)

Shao, Y., Qiao, Y., Xie, B., & Zhou, M. (2019). Intermittent explosive disorder in male juvenile delinquents in China. Frontiers in psychiatry, 10, 485.

https://www.ncbi.nlm.nih.gov/