NP Pediatric SOAP notes examples

NP Pediatric SOAP notes examples, Pediatric SOAP notes example and SOAP notes example for a Pediatric Patient

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Patient Particulars Initials: M.A.J Age: 11 years Gender: Boy Race/ Ethnicity: African American

Subjective:

Chief complaint (CC):  The father states, “The death of his mother has impacted his mood, and I want to make sure that he is fine.”

H.P.I.:  Master AJ is an eleven-year-old boy who presents to the clinic accompanied by his father, the chief informant in this context. The father states that the death of his wife and the boy’s mother appears to have adversely affected the boy’s moods, exhibiting wide mood swings that may last for a few hours to some days on end, so the father wanted to ensure that the boy’s boy is mentally fine. The father reports that the boy’s unusual moods had their onset about two months ago after the murder of the boy’s mother. Additionally, the boy exhibits difficulty falling asleep, uses the whole day playing video games, displays fear of abandonment as he clings to him, and worries about being left alone, besides being aggressive. The father also mentions that the boy must take Melatonin 30 mg qhs to sleep. He also reports noting that the boy is impulsive with explosions of anger. According to the father, the boy is grieving and requires assistance to cope with the situation. However, the patient denies having suicidal thoughts, depression, and auditory or visual hallucinations. In addition, the client constantly mentions his mother as a great one and that there is no single day that passes without him missing her.

Substance Current Use: N/A

Medical History:

  • Current Medication:  Except for melatonin 30mg qhs, A.J. is not on any other O.T.C. or prescription medication
  • Allergies: Noknown allergies to medication, foods, or environmental factors
  • Reproductive Hx: No S.T.I.’s. Negative for reproductive health issues

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R.O.S.: 

  • GENERAL:  A.J. denies feeling hot, while the father reports the son has neither weight gain nor weight loss. However, the father admits the boy has mood changes, difficulties in behavior regulation, unstable relationships, strain falling asleep, clinginess, aggressiveness, and focus directed to video games.
  • HEENT:   Negative for head injury or scars, no inflammation. The patient denies eye pain, itch feeling, and no bloodshot eyes. Negative for hearing impairment or ear pain. Denies having a running nose, nosebleed, or nose pain. Negative for tonsils, no voice hoarseness, and swallowing problems. 
  • SKIN: positive for agony sensation at the slightest movement, standard color, and dryness. 
  • CARDIOVASCULAR: The patient denies having any chest discomfort.
  • RESPIRATORY:  Negative for breathing difficulties and coughs.
  • GASTROINTESTINAL: Negative for diarrhea, vomiting, gas, and bloating.
  • GENITOURINARY:  Denies having frequent urination and pain during urination.
  • NEUROLOGICAL: Both father and son deny the boy has headaches, dementia, walking instability, or abnormal bowel movement.
  • MUSCULOSKELETAL:  Negative for muscle, tendons and ligament pain. 
  • HEMATOLOGICAL: The boy reports no fatigue, bone pain, fever, and night sweats. 
  • Lymphatic: Negative for lymph swelling.
  • ENDOCRINOLOGIC: Father and son admit the boy is anxious and has mania even though the boy denies having heat intolerance.

Objective:

General: the boy is well-dressed and well-nourished for the occasion. 

Vital signs: Heart rate 80 bpm (beat per minute). Respiratory rate: 20; Temperature: 97.4 F (36.6 C). Blood Pressure: 98/119; Height: 55 inches; Weight; 77.5 lbs BMI: 19.2 

HEENT: Head with no abnormal shape but trauma positive. Positive for visual acuity and accommodation of the eyes. The presence of earwax portrays a non-infected ear. By the use of palpation, nasal polyp intact. Negative for throat tumor and culture.

Neurologic: normal symmetric reflexes of the cranial nerves. Negative for motor, vocal deficit, and sensory.

Psychiatric: Positive for unharmonious mood with the content, hasty but appropriate responses, and appropriately dressed. Restless and clicks in mention of his mother.

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Mental Status Examination:

Appearance: 11 yearsAfrican American boy, seem his said age and groomed adequately for the clinic visitation

Behavior: not in agony but does not fully concentrate on the interview, clicks in the mention of the mother.

Motor activity Hyperactive: positive for voice tremor, normal stance, and presence of optimal psychomotor agitation.

Speech: theboy speaks slower than the expectedaverage level of a 10-11 year kid who uses 139-194 words per minute (wpm). He speaks 120 wpm. He takes a long time to answer, although fluent, at a slow rate and a gloomy tone.

Mood: tense

Affect: elated congruent, although not appropriate at times.

Thought Process: Manifest circumstantial tangential of ideas

Thought content: negative suicidal thought

Perception: Positive interpretation of stimuli, olfactory, visual and auditory functions.

Cognition: positive for recognition of places, people, and time.

Memory: he could remember everything about his mother, the place the people they lived with.

Abstract Reasoning: couldrecognize people and items in the surrounding.

Insight moderately: fits his stated age 

Judgment: moderate

Diagnostic Results: 

Cortisol blood test rule out glandular problems 7am to 9 am : 11-19  micrograms per deciliter (mcg/dL) around 5 pm 3-10 mcg/dL

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Assessment: 

Diagnostic Impression/Differential diagnosis

  1. F60.3 personality Disorder (confirmed)

Borderline personality disorder (BPD) is a mental condition that mainly occurs during adolescence or early adulthood. According to Kadiyala (2020), patients with BPD experience difficulties in emotional control, behavior regulation, and maintaining a stable friendship. The treatment of this disorder involves psychotherapy, medication, or the combination of the two. The causative agents of BPD are a combination of genes and other environmental factors. These factors include trauma and abuse, genetic and brain differences. Symptoms range from mild to severe if detected early (Porter et al., 2020). In this case, the patient, an adolescent at eleven years of age, has experienced trauma due to his mother’s death.

Additionally, the boy has brain differences whereby the brain parts in charge of emotion and behavior control experience improper communication. Due to this, the boy becomes aggressive and concentrates only on video games every day. Besides these symptoms, the patient had six of the key symptoms needed to confirm BPD as captured in the mnemonic I DESPAIR. The boy’s identity issues, disordered effects, empty feelings, suicidal behavior (absent), paranoia, abandonment terror, impulsivity, rage, and relationship instability. The boy clings to his father and daily reminisces his moments with his mother.

  • Bipolar Disorder (refuted)

Bipolar disorder is a mental condition characterized by excessive mood swings that lead to hypomania or depression. It is a disorder that can easily be confused with BPD, and it consists of three types. These types share some characteristics with BPD, such as unusual mood shifts and the inability to perform daily duties. However, in BPD, patients have interpersonal issues like unstable relationships (Aguglia et al., 2017). Under this disorder, one becomes depressed; you experience a sad feeling and lack interest in many activities. During mood to hypomania, the patient experiences happiness, full of energy, or irritability. The client does not portray any joy and presents himself full of energy under no circumstances (Miller & Black 2020). All the shows are sadness which he expresses when talking about his mother.

  • Post-Traumatic Stress Disorder (PTSD) (refuted)

This disorder can affect anyone and at any age. Most people diagnosed with PTSD have undergone scary, shocking, or dangerous occurrences Patients with this disease may feel worried or stressed even if they are no more in danger Symptoms typically begin within three months after the traumatic incident (Aaron et al., 2019). To be PTSD-positive, the symptoms have to prevail for more than one month and should be severe enough to disrupt daily activities. According to the boy’s father, the mother died two months ago. This is less than three months the expected period for PTSD symptoms to start. 

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Reflections:

Case Formation and Treatment Plan:

Non-medication interventions should take precedence in BPD treatment with dialectical behavior therapy (D.B.T.). It is important to help manage the behavioral crisis in the boy and reinforce it with medications if the D.B.T. efficacy is found wanting Timäus et al. (2019) mood stabilizers like Lamotrigine or Topiramate is effective in alleviating the mood symptoms, the patient should take Topiramate 50mg P.O. taken four times per day if the boy’s symptoms get worse. Many aspects concerning psychotherapy in BPD treatment need further investigation. For instance, some questions need clarification, like varying psychotherapy approaches and the kind of patients that show a positive response to these approaches. Additionally, pharmacotherapy as a means of BPD treatment requires investigation. The long term management needs continuation, treatment maintenance, and discontinuation. The patient, his family, and school staff will also have patient and caregiver education on how to help a BPD patient.

Follow-ups                                                       

Psychodynamic therapy requires long-term treatment, which will involve 13-26 sessions for patients with BPD. In that case, the provider will include follow-up visits in the treatment plan to enhance patient monitoring of all the treatments administered. The first follow-up will be a month later, after every two months, and finally, twice a year. 

Referrals

Currently, the boy’s psychosocial problems are not severe and hope to manage in the primary care setting. However, the referral will be considered if the symptoms increase in severity.

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References

Aron, C. M., Harvey, S., Hainline, B., Hitchcock, M. E., & Reardon, C. L. (2019). Post-Traumatic stress disorder (PTSD) and other trauma-related mental disorders in elite athletes: a narrative review. British journal of sports medicine53(12), 779-784.

Kadiyala, P. K. (2020). Mnemonics for diagnostic criteria of D.S.M. V mental disorders: a scoping review. General psychiatry33(3).

Miller, J. N., & Black, D. W. (2020). Bipolar disorder and suicide: a review. Current psychiatry reports22(2), 1-10.

Porter, C., Palmier‐Claus, J., Branitsky, A., Mansell, W., Warwick, H., & Varese, F. (2020). Childhood adversity and borderline personality disorder: a meta‐analysis. Acta Psychiatrica Scandinavica141(1), 6-20.

Timäus, C., Meiser, M., Bandelow, B., Engel, K. R., Paschke, A. M., Wiltfang, J., & Wedekind, D. (2019). Pharmacotherapy of borderline personality disorder: what has changed over two decades? A retrospective evaluation of clinical practice. B.M.C. psychiatry19(1), 1-11.

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