Soap 2 Response
16 days ago 10
SOAP2Response.docx
SOAP2Response.docx
STUDENT’S SOAP NOTE : The required discussion response(s) to student or faculty for each weekly question(s) is (are) completed by Friday at 11:59 PM ET for each electronic week. These postings are on different days of the week than the initial post(s). Minimum of 250 words.
Name of Patient: NG
Date of Service: 9/14/26
Session Type: Evaluation/ Intake VIA telehealth, 4:00 pm to 5:00pm
Duration 60 mins
Chief Complaint: “I have been having periods of inattention. I have a history of ADHD and I think I need medications”.
Subjective: Patient is a 37-year-old Caucasian male. He reports that he was diagnosed with ADHD when he was a child. He states that he was taking Adderall and Ritalin until he was 18 years old. He thinks that he was on an additional medication but cannot recall the name. Patient reports he has not been on any medication since the age of 18.
Patient reports that he is easily distracted it can be by noise, people talking or activity. He also states that when he is at work and home he forgets where he put things down and has a hard time finding them. NG states that when he is spoken to, he has difficulty comprehending what is being said to him. He reports that he delays or avoid tasks or projects that requires a lot of thought. He says that he does not have a sense of urgency to finish final projects if the work is challenging.
NG reports that he interrupts others when they are busy. He reports that he cuts others off when they are talking and finishes their sentences. He says he finds it difficult to wait his turn to talk. NG says it is hard for him to sit still and finds himself squirming and fidgeting with his feet or hands. He reports there are times when he is overly energetic and active. NG, provided an example: He says that he came back form a trip and instead of resting he felt the need to keep doing various things.
NG states during work meetings he is able to stay in his seat if he is required to. He states he has no difficulty in remembering appointments or obligations. NG reports no difficulties with organizational, boundaries and talking too much in social settings.
NG reports no issues with sleeping but says he feels tired after his flight back from Australia. He reports that he does have anxiety and believes his blood pressure rises during these incidents. He reports a recent doctors visit but is unsure if his blood pressure was taken, He reports no issues with his appetite. NG reports that he does not use tobacco products, but he does smoke marijuana using a vape pen. Patient states that he has not had any type of therapy but if advised he is open to having therapy. NG reports that he knows of no one that has a history of mental health history. Patient reports he is currently not on any medications and reports no allergies.
Medical History: None
Psychiatric History: ADHD as a child
Current medications: None
Ritalin – Prescribed during childhood stop taking it at the age of 18.
Adderall- Prescribed during childhood stop taking it at the age of 18
Allergies: None
Social History:
Patient is currently employed as a musician and goes on tour a lot. His job includes traveling and he just returned from Australia. Patient has difficulty maintain an exercise routine but says he does exercise occasionally. He denies drinking and tobacco products. He endorses smoking marijuana through a vape pen. Patient reports no history of mental illness in his family.
Review of Systems: Positive for anxiety in certain situations and negative for appetite changes.
Objective:
Patient is a 37-year-old Caucasian male that looks age appropriate. Patient is well groomed and he is able to answer all questions appropriately and without prompts.
Behavior: Patient is very cooperative and engaged throughout this session.
Speech: Normal rate of speech and volume, extremely articulate
Mood: Patient reports feeling good but has anxiety in certain situations
Thought Process.: NG thought process is linear and rational. He can state his issues and able to stay on topic
Thought Content; There are no suicidal, homicidal or self-injury ideations
Cognition: Alert and oriented, no difficulties with short- and long-term memory
Insight: Acknowledges present and prior symptoms of ADHD open to therapy and medication treatment
Judgment: Appears to have good judgement, agreeing to take non-stimulant medications and to obtain psychiatric records.
Assessment and Screening
Self-Report
GAD 7:5
PHQ 9: 1
Diagnosis:
Attention deficit hyperactivity disorder, unspecified type, F90.9 (ICD) (Active)
Anxiety disorder unspecified F41.9 (ICD-10) (Active)
Differential Diagnosis
Cannabis Use -- Cannabis use can affect several neurotransmitters in the brain, including dopamine, serotonin, and norepinephrine. Chronic THC use may also affect the dopamine system and lead to problems with motivation and executive functioning. These effects can mimic or worsen some symptoms of ADHD, such as difficulty with attention, concentration, and motivation. Cannabis use can also make it more difficult for providers to determine whether ADHD medications are improving symptoms of inattention and hyperactivity (Barbuti et al., 2023).
Plan: CW will start taking atomoxetine 25mg by mouth 1 tablet daily dosage is prescribed low to allow gradual titration based on clinical response and tolerability. Atomoxetine is a selective norepinephrine reuptake inhibitor that is approved for the treatment of ADHD in children, adolescents, and adults. It works by blocking the reuptake of norepinephrine in the brain, which increases the amount of norepinephrine available. Atomoxetine can also affect dopamine levels in certain areas of the brain, including the prefrontal cortex, which plays an important role in attention and concentration (Fu et al., 2021). Patient was educated on possible side effects of atomoxetine which can include nausea, decrease in appetite, increase in blood. pressure, increase in heart rate and fatigue. Patient advised to take this medication with food or a snack. Patient advised to purchase a blood pressure cuff and take his blood pressure daily. Patient agreed to obtain prior psychiatric records from childhood. Patient recommend to practice mindful techniques to help with impulsive reactions and inattention. Mindfulness is a practice that involves focusing a person’s attention on what is happening in the present moment while approaching their thoughts and experiences with an open mind, curiosity, and acceptance (Mitchell et al., 2015). Recommendations to break larger task in to several simple task. Patient also advise to cease using marijuana while taking stimulant therapy. Cannabis use disorder is commonly seen in individuals with mental health disorders, especially those diagnosed with ADHD. According to Barbuti et al. (2023), ADHD was diagnosed in approximately one-third of adolescents who experienced cannabis use disorder, cannabis abuse, or problematic cannabis use. Patient was also educated on using cannabis because it may increase anxiety or cause possible cardiac issues. A therapy referral was discussed and patient is open to therapy. Patient to return in 1 week.
Bobbie Gilbert RN
References
Barbuti, M., Maiello, M., Spera, V., Pallucchini, A., Brancati, G. E., Maremmani, A. G. I., Perugi, G., & Maremmani, I. (2023). Challenges of treating ADHD with comorbid substance use disorder: Considerations for the clinician. Journal of Clinical Medicine, 12(9), Article 3096. https://doi.org/10.3390/jcm12093096
Fu, D., Wu, D.-D., Guo, H.-L., Hu, Y.-H., Xia, Y., Ji, X., Fang, W.-R., Li, Y.-M., Xu, J., Chen, F., & Liu, Q.-Q. (2021). The mechanism, clinical efficacy, safety, and dosage regimen of atomoxetine for ADHD therapy in children: A narrative review. Frontiers in Psychiatry, 12, Article 780921. https://doi.org/10.3389/fpsyt.2021.780921
Mitchell, J. T., Zylowska, L., & Kollins, S. H. (2015). Mindfulness meditation training for attention-deficit/hyperactivity disorder in adulthood: Current empirical support, treatment overview, and future directions. Cognitive and Behavioral Practice, 22(2), 172–191. https://doi.org/10.1016/j.cbpra.2014.10.002
SOAP2Response.docx
STUDENT’S SOAP NOTE : The required discussion response(s) to student or faculty for each weekly question(s) is (are) completed by Friday at 11:59 PM ET for each electronic week. These postings are on different days of the week than the initial post(s). Minimum of 250 words.
Name of Patient: NG
Date of Service: 9/14/26
Session Type: Evaluation/ Intake VIA telehealth, 4:00 pm to 5:00pm
Duration 60 mins
Chief Complaint: “I have been having periods of inattention. I have a history of ADHD and I think I need medications”.
Subjective: Patient is a 37-year-old Caucasian male. He reports that he was diagnosed with ADHD when he was a child. He states that he was taking Adderall and Ritalin until he was 18 years old. He thinks that he was on an additional medication but cannot recall the name. Patient reports he has not been on any medication since the age of 18.
Patient reports that he is easily distracted it can be by noise, people talking or activity. He also states that when he is at work and home he forgets where he put things down and has a hard time finding them. NG states that when he is spoken to, he has difficulty comprehending what is being said to him. He reports that he delays or avoid tasks or projects that requires a lot of thought. He says that he does not have a sense of urgency to finish final projects if the work is challenging.
NG reports that he interrupts others when they are busy. He reports that he cuts others off when they are talking and finishes their sentences. He says he finds it difficult to wait his turn to talk. NG says it is hard for him to sit still and finds himself squirming and fidgeting with his feet or hands. He reports there are times when he is overly energetic and active. NG, provided an example: He says that he came back form a trip and instead of resting he felt the need to keep doing various things.
NG states during work meetings he is able to stay in his seat if he is required to. He states he has no difficulty in remembering appointments or obligations. NG reports no difficulties with organizational, boundaries and talking too much in social settings.
NG reports no issues with sleeping but says he feels tired after his flight back from Australia. He reports that he does have anxiety and believes his blood pressure rises during these incidents. He reports a recent doctors visit but is unsure if his blood pressure was taken, He reports no issues with his appetite. NG reports that he does not use tobacco products, but he does smoke marijuana using a vape pen. Patient states that he has not had any type of therapy but if advised he is open to having therapy. NG reports that he knows of no one that has a history of mental health history. Patient reports he is currently not on any medications and reports no allergies.
Medical History: None
Psychiatric History: ADHD as a child
Current medications: None
Ritalin – Prescribed during childhood stop taking it at the age of 18.
Adderall- Prescribed during childhood stop taking it at the age of 18
Allergies: None
Social History:
Patient is currently employed as a musician and goes on tour a lot. His job includes traveling and he just returned from Australia. Patient has difficulty maintain an exercise routine but says he does exercise occasionally. He denies drinking and tobacco products. He endorses smoking marijuana through a vape pen. Patient reports no history of mental illness in his family.
Review of Systems: Positive for anxiety in certain situations and negative for appetite changes.
Objective:
Patient is a 37-year-old Caucasian male that looks age appropriate. Patient is well groomed and he is able to answer all questions appropriately and without prompts.
Behavior: Patient is very cooperative and engaged throughout this session.
Speech: Normal rate of speech and volume, extremely articulate
Mood: Patient reports feeling good but has anxiety in certain situations
Thought Process.: NG thought process is linear and rational. He can state his issues and able to stay on topic
Thought Content; There are no suicidal, homicidal or self-injury ideations
Cognition: Alert and oriented, no difficulties with short- and long-term memory
Insight: Acknowledges present and prior symptoms of ADHD open to therapy and medication treatment
Judgment: Appears to have good judgement, agreeing to take non-stimulant medications and to obtain psychiatric records.
Assessment and Screening
Self-Report
GAD 7:5
PHQ 9: 1
Diagnosis:
Attention deficit hyperactivity disorder, unspecified type, F90.9 (ICD) (Active)
Anxiety disorder unspecified F41.9 (ICD-10) (Active)
Differential Diagnosis
Cannabis Use -- Cannabis use can affect several neurotransmitters in the brain, including dopamine, serotonin, and norepinephrine. Chronic THC use may also affect the dopamine system and lead to problems with motivation and executive functioning. These effects can mimic or worsen some symptoms of ADHD, such as difficulty with attention, concentration, and motivation. Cannabis use can also make it more difficult for providers to determine whether ADHD medications are improving symptoms of inattention and hyperactivity (Barbuti et al., 2023).
Plan: CW will start taking atomoxetine 25mg by mouth 1 tablet daily dosage is prescribed low to allow gradual titration based on clinical response and tolerability. Atomoxetine is a selective norepinephrine reuptake inhibitor that is approved for the treatment of ADHD in children, adolescents, and adults. It works by blocking the reuptake of norepinephrine in the brain, which increases the amount of norepinephrine available. Atomoxetine can also affect dopamine levels in certain areas of the brain, including the prefrontal cortex, which plays an important role in attention and concentration (Fu et al., 2021). Patient was educated on possible side effects of atomoxetine which can include nausea, decrease in appetite, increase in blood. pressure, increase in heart rate and fatigue. Patient advised to take this medication with food or a snack. Patient advised to purchase a blood pressure cuff and take his blood pressure daily. Patient agreed to obtain prior psychiatric records from childhood. Patient recommend to practice mindful techniques to help with impulsive reactions and inattention. Mindfulness is a practice that involves focusing a person’s attention on what is happening in the present moment while approaching their thoughts and experiences with an open mind, curiosity, and acceptance (Mitchell et al., 2015). Recommendations to break larger task in to several simple task. Patient also advise to cease using marijuana while taking stimulant therapy. Cannabis use disorder is commonly seen in individuals with mental health disorders, especially those diagnosed with ADHD. According to Barbuti et al. (2023), ADHD was diagnosed in approximately one-third of adolescents who experienced cannabis use disorder, cannabis abuse, or problematic cannabis use. Patient was also educated on using cannabis because it may increase anxiety or cause possible cardiac issues. A therapy referral was discussed and patient is open to therapy. Patient to return in 1 week.
Bobbie Gilbert RN
References
Barbuti, M., Maiello, M., Spera, V., Pallucchini, A., Brancati, G. E., Maremmani, A. G. I., Perugi, G., & Maremmani, I. (2023). Challenges of treating ADHD with comorbid substance use disorder: Considerations for the clinician. Journal of Clinical Medicine, 12(9), Article 3096. https://doi.org/10.3390/jcm12093096
Fu, D., Wu, D.-D., Guo, H.-L., Hu, Y.-H., Xia, Y., Ji, X., Fang, W.-R., Li, Y.-M., Xu, J., Chen, F., & Liu, Q.-Q. (2021). The mechanism, clinical efficacy, safety, and dosage regimen of atomoxetine for ADHD therapy in children: A narrative review. Frontiers in Psychiatry, 12, Article 780921. https://doi.org/10.3389/fpsyt.2021.780921
Mitchell, J. T., Zylowska, L., & Kollins, S. H. (2015). Mindfulness meditation training for attention-deficit/hyperactivity disorder in adulthood: Current empirical support, treatment overview, and future directions. Cognitive and Behavioral Practice, 22(2), 172–191. https://doi.org/10.1016/j.cbpra.2014.10.002