Assignment 2: Focused SOAP Note and Patient Case Presentation

Case study presentation

Cc Psych eval

HISTORY: Aiden is a 5-year-old boy. This evaluation was requested because "the primary care

doctor want us to have an evaluation for ADHD". Mother report that patient has "been having a lot

of issues at school. He walks around the class, hit, push, shove other students, interupt others,

unable to wait his turn or complete his work. he cannot work in group setting. he even pushed

someone yesterday at school and he was send home early. the other person has injury. the teacher

had to put his chair at her table just to prevent distraction but it has not helped". mother report that

patient's classroom teacher and herself completed the vanderbilt form that was provided by pcp.

Information Received From: patient and mother

Behavior Described In:

Aiden exhibits hyperactive and attentional difficulties both in school and at home.

ADHD Symptoms:

Aiden exhibits symptoms of inattention. Careless mistakes are typical. He reports difficulty

sustaining attention. He does not seem to listen when spoken to directly. He often needs directions

repeated. Projects or tasks are often not completed. He needs extra time to complete his

assignments. Aiden reports being disorganized. He finds it difficult to keep his book bag or school

locket organized. Tasks requiring sustained mental effort are difficult for Aiden to accomplish. His

mind easily wanders or becomes distracted. Aiden is easily distracted by other people. by the

radio. by noises. He describes being inattentive. He often needs directions repeated. He has a

short attention span. Aiden needs supervision or frequent redirection.

Aiden exhibits signs of hyperactivity. He exhibits restlessness or fidgety behavior. This

behavior is evident during school hours. He has a tendency to frequently leave his seat. Playing

quietly is difficult for Aiden . He is always “on the go” , and is unable to be still for an extended

period of time. He is easily bored and changes activities frequently. Aiden 's excessive movement

has been noted. He is fidgety or squirms when required to sit still for a period of time. He

frequently jumps or climbs.

Aiden exhibits signs of impulsive behavior. He frequently interrupts others. He has

problems waiting for his turn. He often acts in a reckless manner (has sustain multiple injury from

jumping, hiting his head etc) .

Severity:

The attentional difficulties described cause moderate impairment in Aiden 's functioning.

Respiratory: hx of asthma

Review of all other systems reviewed were negative. No Test Results were received.

The Vanderbilt Assessment Scale:

A questionnaire that scans for symptoms of ADHD, ODD, Conduct Disorder, and

anxiety/depression in children. Aiden 's assessment results are as follows:

*Parent's Assessment:

Scoring indicates the presence of ADHD, combined Hyperactive/Inattentive type.

*Teacher's Assessment: Scoring indicates the presence of ADHD, combined

Hyperactive/Inattentive type.

PAST PSYCHIATRIC HISTORY:

Psychiatric Hospitalization:

Aiden has never been psychiatrically hospitalized.

Outpatient Treatment:

Has never received outpatient mental health treatment.

Suicidal/Self Injurious:

Aiden has no history of suicidal or self injurious behavior.

Psychotropic Medication History:

Psychotropic medications have never been prescribed for Aiden

EXAM: Aiden presents as happy, distracted, well groomed, normal weight child. He exhibits

speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language

skills are appropriate for age.. Affect is appropriate, full range, and congruent with mood.

Associations are intact and logical. There are no apparent signs of hallucinations, delusions,

bizarre behaviors, or other indicators of psychotic process. cognitive functioning appropriate for

age. Insight into problems appears fair. Judgment appears to be poor. He is easily distracted. A

short attention span is evident. There is physical hyperactivity. Aiden is fidgety. Aiden is restless

during assessment. Aiden was intrusive during the examination. Supine blood pressure is 98 / 52.

Supine pulse rate is 69. Weight is 65 lbs. (29.5 Kg). TREATMENT PLAN she was

Hesitant due to cultural background, educational material on medication and diagnosis given to

mother who was encouraged to call and make appointment when she is ready to begin treatment.