ADHD Julia, a 19-year-old female college student, came to a school clinic for help with academic problems. Since starting college six months earlier, she h
ADHD
Julia, a 19-year-old female college student, came to a school clinic for help with academic problems. Since starting college six months earlier, she had done poorly on tests and could not manage her study schedule. Her worries about flunking out of college were causing her poor sleep, poor focus and lost hope. After a week of low grades, she returned home and told her family she should drop out of college. Her mother brought her to the clinic where she and her older brother had been treated for ADHD when they were younger. She wondered if his ADHD might be causing his problems, or whether he had outgrown it.
Julia had been to the clinic when she was 9 years old and had been diagnosed with ADHD. Notes from that evaluation showed Julia had been in trouble at school for getting out of her seat, losing things, not following instructions, not completing homework and not listening.
A psychologist also confirmed reading problems during the evaluation. Because Julia’s problems did not meet the standard for a learning disability diagnosis, she could not receive special education services. Julia’s primary care doctor had proposed medication, but her mother refused. Instead, she hired a tutor to help her daughter “with concentration and reading.”
Since starting college, Julia said he often had trouble staying focused while reading and listening to lectures. Because of his stress at school, she had trouble falling asleep, had poor energy and didn’t “have fun” like his peers.
Julia’s older brother had ADHD. Her father, who died when Julia was seven, had dyslexia (a reading disorder). Her father had dropped out of community college after one semester.
Julia was referred to a psychologist for more testing, and the doctor diagnosed her with ADHD. The report stated that Julia had certain problems with reading fluency and comprehension (reading quickly and know the correct meaning), as well as spelling and writing. When she was first assessed at age 9, the standards for ADHD required six of nine symptoms. She had been diagnosed with the combined type of ADHD, because the specialty clinic had found at least six symptoms in inattention and hyperactivity/impulsivity. With DSM-5, only five symptoms are needed for people age 17 and older. At age 19, Julia met the standards for ADHD and for a specific learning disorder. With the correct diagnosis, he was able to receive services for academic support for her college studies.
American Psychiatric Association. (2021). ADHD patient stories. Understanding Mental Disorders: Your Guide to DSM5. American Psychiatric Publishing, Inc.
What is your diagnosis and treatment plan for this case? Include the following:
Pharmacological tx
Non-pharmacological to
Patient Education
Referral to other providers
Follow-up
Use the Case Study template to show your assessment collection data as well as the thought processes for diagnosis and treatment. Support your diagnosis and treatment plan with a minimum of two reference in APA form.
Instructions
1. Select a pediatric/adolescent client or case that you have worked within either in your current nursing practice or your PMHNP student clinical setting. Ensure that you correctly remove the appropriate information (name, etc.) to remain HIPAA compliant.
2. Prepare a full mental health evaluation on your pediatric/adolescent client. Use the resources presented in the course to help guide your evaluation. Kaplan & Saddock’s Synopsis of Psychiatry has a robust list of the categories of information you should collect and present in your evaluation report (5.1. Parts of the Initial Psychiatric Interview). This should include the following:
1. A full psychiatric, physical, social, family, and birth and developmental history including verbal reports of the client, your observations of the client, and a summary of any diagnostic aids that you have used.
2. The use of at least one psychiatric screening or assessment tool from the literature to assist in your assessment of the client
3. A full physical assessment in addition to the mental status exam and psychiatric history
3. Develop a DSM-5 diagnostic assessment:
1. Support your diagnosis through a thoughtful, evidence-based rationale of the data collected in your evaluation.
4. Propose a practical, evidence-based plan of care:
1. Keep in mind the role of the psychiatric-mental health nurse practitioner is to assess all aspects of the patient’s health status, including health promotion, and disease prevention. Psychiatric care is interdisciplinary. Your plan of care may include the use of other mental health professionals for the delivery of appropriate care. For example, someone who has been chronically back pain, and has been out of work may have these factors contributing to his or her depression and may require a pain specialist and social services to address those aspects of the client’s poor psychological functioning.
Requirements
1. Support your assessment, diagnosis, and treatment and management plan with appropriate literature citations.
2. The paper should be no more than ten pages in length, not including a title page and references.
3. Use current APA formatting and citations.
4. Acronyms should not be used.
5. The assessment must be well written and be of professional quality. It must be clear, and well developed, free of spelling, grammatical, and syntactical errors and in full sentences format.
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Criteria |
Clinical Notes |
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Informed Consent |
Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion) |
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Subjective |
Verify Patient Name: DOB: Minor: Accompanied by: Demographic: Gender Identifier Note: CC: HPI: Pertinent history in record and from patient: X During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME. Patient self-esteem appears fair, no reported feelings of excessive guilt, no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy, no reported changes in concentration or memory. Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks. Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature. SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors. Allergies: NKDFA. (medication & food) Past Medical Hx: Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury. Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C. Surgical history no surgical history reported If Minor obtain Developmental Hx: (most often from parents), in utero, birth and delivery hx, early childhood, school hx, behavior, etc… Nutritional status (this is an important component to gauge how well the mind and body are being nourished for full function. Ex: lack of iodine create thyroid issues, thyroid issues creates metabolism issues which affects function of cognition, mood, etc…) Past Psychiatric Hx: Previous psychiatric diagnoses: none reported. Describes stable course of illness. Previous medication trials: none reported. Safety concerns: History of Violence to Self: none reported History of Violence t o Others: none reported Auditory Hallucinations: Visual Hallucinations: Mental health treatment history discussed: History of outpatient treatment: not reported Previous psychiatric hospitalizations: not reported Prior substance abuse treatment: not reported Trauma history: Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events. Substance Use: Client denies use or dependence on nicotine/tobacco products. Client does not report abuse of or dependence on ETOH, and other illicit drugs. Current Medications: No current medications. (Contraceptives): Supplements: Past Psych Med Trials: Family Medical Hx: Family Psychiatric Hx: Substance use Suicides Psychiatric diagnoses/hospitalization Developmental diagnoses Social History: Occupational History: currently unemployed. Denies previous occupational hx Military service History: Denies previous military hx. Education history: completed HS and vocational certificate Developmental History: no significant details reported. (Childhood History) Legal History: no reported/known legal issues, no reported/known conservator or guardian. Spiritual/Cultural Considerations: none reported. ROS: Constitutional: No report of fever or weight loss. Eyes: No report of acute vision changes or eye pain. ENT: No report of hearing changes or difficulty swallowing. Cardiac: No report of chest pain, edema or orthopnea. Respiratory: Denies dyspnea, cough or wheeze. GI: No report of abdominal pain. GU: No report of dysuria or hematuria. Musculoskeletal: No report of joint pain or swelling. Skin: No report of rash, lesion, abrasions. Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia. Hematologic: No report of blood clots or easy bleeding. Allergy: No report of hives or allergic reaction. Reproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…) |
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Verify Patient: Name, Assigned identification number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo. Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview. HPI: , Past Medical and Psychiatric History, Current Medications, Previous Psych Med trials, Allergies. Social History, Family History. Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” |
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Objective |
Temp: BP: HR: R: O2: Pain: Ht: Wt: BMI: BMI Range: LABS: Lab findings WNL Tox screen: Negative Alcohol: Negative HCG: N/A Physical Exam: MSE: Patient is cooperative and conversant, appears without acute distress, and fully oriented x 4. Patient is dressed appropriately for age and season. Psychomotor activity appears within normal. Presents with appropriate eye contact, euthymic affect – full, even, congruent with reported mood of “x”. Speech: spontaneous, normal rate, appropriate volume/tone with no problems expressing self. TC: no abnormal content elicited, denies suicidal ideation and denies homicidal ideation. Process appears linear, coherent, goal-directed. Cognition appears grossly intact with appropriate attention span & concentration and average fund of knowledge. Judgment appears fair . Insight appears fair The patient is able to articulate needs, is motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning. Diagnostic testing: · PHQ-9, psychiatric assessment |
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This is where the “facts” are located. Vitals, **Physical Exam (if performed, will not be performed every visit in every setting) Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results. |
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Assessment |
DSM5 Diagnosis: with ICD-10 codes Dx: – Dx: – Dx: – Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent. Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment. |
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Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment. Informed Consent Ability |
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Plan |
Inpatient: Psychiatric. Admits to X as per HPI. Estimated stay 3-5 days Patient is found to be stable and has control of behavior. Patient likely poses a minimal risk to self and a minimal risk to others at this time. Patient denies abnormal perceptions and does not appear to be responding to internal stimuli. Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic: · No changes to current medication, as listed in chart, at this time · or…Zoloft is an excellent option for many women who experience any menstrual cycle complaints. I usually start at 50 mg and move to 100 week 6-8. f/u within 2 weeks initially then every 6-8 weeks. · Psychotherapy referral for CBT Education, including health promotion, maintenance, and psychosocial needs · Importance of medication · Discussed current tobacco use. NRT not indicated. · Safety planning · Discuss worsening sx and when to contact office or report to ED Referrals: endocrinologist for diabetes Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 2 weeks ☒ > 50% time spent counseling/coordination of care. Time spent in Psychotherapy 18 minutes Visit lasted 55 minutes Billing Codes for visit: XX XX XX ____________________________________________ NAME, TITLE Date: Click here to enter a date. Time: X |
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Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment and include patient education. |
Initial Psychiatric SOAP Note Template
There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting.
Writing Assignment Grading Rubric
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Assignment Criteria |
Level III |
Level II |
Level I |
Not Present |
|
Criteria 1 |
Level III Max Points: 20 |
Level II Max Points: 16 |
Level I Max Points: 12 |
Not Present 0 Points |
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Content of Paper |
· Demonstrates a well-articulated understanding of the subject matter in a clear, complex, and informative manner · Develops content and theories are well · Links content to the paper requirements and practical experience · Includes relevant material that fulfills all objectives of the paper · Uses scholarly resources that were not provided in the course materials · Completes all instruction requirements |
· Demonstrates an understanding of the subject matter · Explains and applies knowledge of evidence-based practice, ethics, theory, and/or role · Uses a variety of scholarly resources from the course material and some that were not provided in the course materials · Includes relevant material that fulfills all objectives of the paper. · Completes all instruction requirements |
· Demonstrates a moderate understanding of the subject matter · Summarizes content with minimal application to evidence-based practice, theory, or role-development · Presents content but is missing depth and or development · Uses only scholarly resources that were provided in the course materials Completes most instruction requirements |
· Does not meet the criteria |
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Criteria 2 |
Level III Max Points: 20 |
Level II Max Points: 16 |
Level I Max Points: 12 |
Not Present 0 Points |
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Analysis and Synthesis of Paper Content and Meaning |
· Provides critical analysis in an accurate, clear, concise, and complete presentation of the required content · Synthesizes information from scholarly resources · Provides new information or insight related to the context of the assignment with both supportive and alternative information or viewpoints · Completes all instruction requirements |
· Provides evidence of further synthesis of course content via scholarly resources · Synthesizes information to help fulfill paper requirements · Supports content with at least one viewpoint. · Completes all instruction requirements |
· Lacks clarification or new information · Supports content with scholarly reference without adding any new information or insight · Provides content that may be confusing or unclear, and the summary may be incomplete · Completes most instruction requirements |
· Does not meet the criteria |
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Criteria 3 |
Level III Max Points: 20 |
Level II Max Points: 16 |
Level I Max
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