Soap Note

Subjective:

CC (chief complaint): “My son is still hyperactive and restless”

HPI: The client is 10-year-old male who presents to the practice with his mother ……………………….. He has currently prescribed Adderall 5 mg PO daily to manage his Attention-deficit hyperactivity disorder (ADHD) disorder which he was started on two weeks ago. …………………………………………………. The client has no medical history.

Substance Current Use: NA

Medical History: NA

· Current Medications: Adderall 5 mg PO daily

· Allergies: None reported

· Reproductive Hx: N/A

· Immunizations: The client is up to date on all his vaccines.

· Surgeries: None reported.

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Physical Examination

Vital Signs: B/P , HR , Temp. , Height, Weight .

General:

Neurological:

Eyes:.

Ears:

Nose:

Neck:

Breast:

Genitourinary:

Abdomen:

Cardiovascular:

Diagnostic results:

Lead level: to rule lead poisoning

Mental Status Examination:

Assessment:

Differential Diagnoses:

1. Attention-deficit hyperactivity disorder ADHD

2. Conduct Disorder:

3. Autism:

Diagnostic Impression: Attention-deficit hyperactivity disorder (ADHD).

DSM-5 Diagnostic Criteria: Attention-deficit hyperactivity disorder (ADHD).

The DSM-5 diagnostic criteria guideline ……………………..

Case Formulation and Treatment Plan: 

Case Formulation

C.G is a 10-year-old African American male who presents to the practice …………………………….

Treatment Plan

Pharmacological Intervention

Increase Adderall to 5 mg twice daily. ……………………………………….

Non-pharmacological Interventions

Cognitive behavioral therapy ……………………………

Reflections

.

References