SOAP Note: Cory

 

6/6/2022 1400

 

Cory , 16-year-old male

 

Referred by mother; reliable source

 

SUBJECTIVE

 

Identifying Data:

 

C.R. is a 16-year-old Caucasian male who was referred to the clinic by his mother for concerns of difficulty concentrating and poor grades. The client presented to the clinic with his mother but was initially interviewed alone. Client’s mother did join at the end of the session. Information was gathered from both the client and his mother.

 

Chief Complaint:

 

“Difficulty concentrating and grades keep getting worse”

 

Psychiatric and Medical History of Present Illness:

 

C.R. is a 16-year-old Caucasian male who presents today for evaluation of his poor grades and difficulty concentrating. Client reports that his grades have been getting worse every semester. He reports he is a sophomore this school year, but that he almost failed several classes his freshman year. He states it was due to forgetting to do homework, not paying attention, and forgetting to study. He reports that he has a difficult time concentrating and sitting still in class. This is especially true for classes like math, reading, writing, science, and history versus gym and woodshop. He states those classes are easier for him, because he can move around and are engaged in activities. He reports he feels like he struggles more in school compared to other students. He states that teachers report that he makes careless mistakes, doesn’t pay attention, lacks attention to details, and doodles too much. He reports that he has always struggled in school, and that his grades have varied between Bs and Cs and occasionally a few Ds. He reports he is able to pay attention in school better if he has gym or woodshop at the beginning of the day because he can get some energy out. He also believes that he completes coursework better in the classroom versus at home. Completing coursework at home is a struggle and further frustrates him, because he reports he always forgets something that interferes with completing his work and because he gets easily distracted by other things. C.R. states he does better engaging in activities outside like sports or yard work. He reports playing video games 2-3 hours a night and can concentrate on his games easily because he enjoys them. He states that his mother complains that he loses things, is disorganized and forgetful, and does not manage his time well. In addition, he reports that his relationship with his mother is becoming strained and that they used to be much closer. He reports that he feels like he is disappointing her, which makes him feel sad. He also reports that his mother will no longer let him play sports until his grades improve. This makes him very upset because he is passionate about playing sports and enjoys playing sports with his friends. His mother also does not let him interact with friends during the week because of his grades and he reports missing those interactions. He reports his sleep is okay and that it sometimes takes a while to fall asleep because it takes time for his body to calm down. C.R. denies suicidal and homicidal thoughts. He also denies auditory, visual, and tactile hallucinations and does not appear to be responding to internal stimuli. No delusional thought content present during the session. No racing thoughts or pressured speech. No manic or hypomanic symptoms. He denies feeling depressed or hopeless, but reports feeling sad because he wants to be able to play sports again.

 

Past Medical History:

 

Chickenpox at 4 years old. No prior hospitalizations or significant health problems. Denies history of head injuries. Last physical was September 2021 for school. No prior surgeries. Age-appropriate immunizations are up to date as per immunization registry.

 

Allergies: No known medication allergies. Allergic to bees.

 

Medications: No current medications

 

Past Psychiatric History:

 

No prior psychiatric history. Client denies engaging in psychotherapy or medication therapy. He denies prior psychiatric hospitalizations. Denies previous suicide attempts or self-destructive behavior. Denies a history of aggression or violence.

                         

History of Substance Use:

 

He denies alcohol, tobacco, and illicit drug use or abuse. He admits to drinking caffeinated drinks such as energy drinks, but reports not on a regular basis.

 

Developmental, Personal, and Social History:

 

Born and raised in Wynot, South Dakota. Born male and identifies as male. He reports he hit all developmental milestones on time. He currently lives with both parents in a single-family home in Wynot, South Dakota. He has one older sister who is currently enrolled in college and only home during the winter and summer breaks. C.R. is currently a sophomore in high school and is not currently employed. His support system includes his parents and friends; however, both have been affected by his poor grades. C.R. denies legal problems. He denies a history of physical, sexual, and verbal abuse.

 

Family History:

 

C.R. denies a family psychiatric history. Both parents are alive and healthy. His older sister is alive and healthy. C.R. denies substance use and abuse in the family.

 

OBJECTIVE

 

Vital Signs:

 

BP 115/60 right arm, sitting. Heart rate (HR) 78 and regular. Respiratory rate (RR) 16. Temperature (oral) 98.6°F. Sp02 97% on RA

 

Review of Systems (ROS):

 

ROS noncontributory.     

 

Mental Status Exam:

 

GABA- Client looks stated age, has intermittent eye contact, appropriate gestures and posture, appears appropriately dressed for weather with good hygiene, is without abnormal movements or ticks, and is cooperative during assessment.

 

Mood- “sad and frustrated”

 

Affect- stable, full, sad, and congruent

 

Speech- controlled rate and rhythm, normal volume and tone, mumbled articulation at times

 

Thought Process- logical, goal directed, and organized

 

Thought Content- No intrusive thoughts, delusions, ruminations, hallucinations, obsessions, phobias, suicidal ideation (passive, active, or active with a plan), or homicidal ideation

 

Insight and Judgement- Good insight and sound judgement

 

Cognition- alert and oriented to person, date, time, and place. Memory is intact to recent and remote events. Average intelligence. Attention and concentration intact.

 

ASSESSMENT

 

Findings/Clinical Impression:

 

The client C.R. is a 16-year-old Caucasian male who presents today for evaluation of his poor grades and difficulty concentrating. He has no previous psychiatric history or previous medical history. His current symptoms include forgetfulness, distractibility, loosing things for tasks, avoiding sustained mental effort, disorganized, lack of following through, difficulty listening when spoken to, decrease concentration, careless mistakes, difficulty sitting still, fidgeting, and feeling of excessive energy or on the go. These symptoms are present in both the home and school setting and have been present for more than six months. These symptoms have been affecting his ability to perform in school, and his grades have continued to get worse over the past year. In addition, these symptoms are affecting his personal relationships with his mother and friends. C.R. has never received treatment for these symptoms prior to this assessment. He does not endorse anhedonia, weight changes, decreased energy, guilt, worthlessness, hopelessness, or regret. He denies feeling suicidal or ever having suicidal thoughts. He does not endorse feeling worried or anxious. No evidence of internal stimuli or intrusive thoughts. He does not endorse racing thoughts or manic or hypomanic symptoms. His symptoms are consistent with attention deficit hyperactivity disorder (ADHD) (American Psychiatric Association, 2013; Roh & Kim, 2021). Further testing will be arranged to evaluate for ADHD. Client will return to clinic in two weeks to review test results and to further assess the need for treatment. Will consider initiating medications at follow up appointment.

 

Diagnosis and Differentials:

 

314.01(F90.2) Attention-Deficit/Hyperactivity Disorder-Combined Presentation

 

Rationale: C.R. is endorsing symptoms consistent with ADHD which include forgetfulness, distractibility, loosing things for tasks, avoiding sustained mental effort, disorganized, lack of following through, difficulty listening when spoken to, decrease concentration, careless mistakes, difficulty sitting still, fidgeting, and feeling of excessive energy or on the go (American Psychiatric Association, 2013; Roh & Kim, 2021). These symptoms do not occur in conjunction with a psychotic disorder and are not from another mental disorder (American Psychiatric Association, 2013). In addition, his symptoms occur in more than one setting to include home and school, and have been present for longer than six months (American Psychiatric Association, 2013; Roh & Kim, 2021). Furthermore, his symptoms are affecting his performance in school and social relationships (American Psychiatric Association, 2013; Roh & Kim, 2021).

 

Treatment Goal/Objective:

 

Improve ability to focus, concentrate, and listen in school and at home as demonstrated by improvements in grades and following through with delegated tasks.

 

PLAN

 

Treatment Plan:

 

Treatment for ADHD can include a combination of behavioral interventions, medications, and education interventions (UpToDate, 2022).

 

Diagnostic studies:

 

Baseline lab work should be done before initiating medications and should include CBC with differential, CMP, liver function tests, and thyroid tests (Puzantian & Carlat, 2016).

 

Pharmacologic Interventions:

 

Medication is recommended as the first line treatment for ADHD in children/adolescents older than 6 years old (UpToDate, 2022). After the completion of further testing, I would discuss the option of initiating medications. There are several options available to include stimulants versus non stimulants (Puzantian & Carlat, 2016; Roh & Kim, 2021). Therefore, these options would be reviewed with C.R. and his mother. I would suggest one of the following medications for the management of C.R.’s ADHD.

 

•             Concerta 18mg PO QAM (Puzantian & Carlat, 2016).

 

o             Common side effects include insomnia, headache, nervousness, abdominal pain, nausea, vomiting, anorexia, weight loss, affect lability, and ticks (Puzantian & Carlat, 2016).

 

•             Strattera 40mg PO QAM (Puzantian & Carlat, 2016).

 

o             Common side effects include headache, abdominal pain, decreased appetite, fatigue, nausea, and vomiting. (Puzantian & Carlat, 2016). Serious but rare side effects include an increased risk for suicidality, severe hepatic injury, and increased blood pressure and heart rate (Puzantian & Carlat, 2016).

 

Non-pharmacologic Interventions:

 

Behavioral interventions such as modifications in the physical and social environment have demonstrated to be beneficial when utilized in conjunction with medication therapy (UpToDate, 2022). It has shown to lower medication doses and improve relationships and social skills as compared to medications alone (UpToDate, 2022).

 

Referrals:

 

A referral for further psychological testing to include the use of a specific ADHD scale, such as the Vanderbilt Assessment Scales (UpToDate, 2022).

 

Education/Anticipatory Guidance:

 

Effective treatment for ADHD should include providing education regarding the diagnosis to the patient, their caregivers, and their teachers (UpToDate, 2022). Education should include symptoms and disease prognosis (UpToDate, 2022). In addition, education should include possible treatment options, such as behavioral interventions, medication, and school-based interventions (UpToDate, 2022).

 

Follow Up:

 

C.R. should have a follow up in two weeks to review the results of his testing and determine the need for further treatment.

 

References

 

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) (DSM-5). APA Press.

 

Puzantian, T. & Carlat, D. (2016). Medication Fact Book for Psychiatric Practice (3rd Ed.). Newburport, MA: Carlat Publishing.

 

Roh, H., & Kim, B. (2021). A brief replication study comparing stimulants and non-stimulants for Attention-Deficit/Hyperactivity Disorder treatment with a focus on the compliance, efficacy, and satisfaction. Soa–Ch’ongsonyon Chongsin Uihak = Journal of Child & Adolescent Psychiatry, 32(1), 10–16. https://doi.org/10.5765/jkacap.200024

 

UpToDate. (2022). Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis. Retrieved from: https://www-uptodate-com.regiscollege.idm.oclc.org/contents/attention-deficit-hyperactivity-disorder-in-children-and-adolescents-overview-of-treatment-and-prognosis?search=ADHD&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H24

 

UpToDate. (2022). Attention deficit hyperactivity disorder in children and adolescents: Clinical features and diagnosis. Retrieved from: https://www-uptodate-com.regiscollege.idm.oclc.org/contents/attention-deficit-hyperactivity-disorder-in-children-and-adolescents-clinical-features-and-diagnosis?search=ADHD&topicRef=623&source=see_link

 

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