NSG 6435 Week 6 Soap Note Meissner D

C ONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Note s 11202 3 Page 1 of 4 Student Name: Dina Meissner Course: NSG 6435 Patient Name: (Initials ONLY) MO Date: 1/2/24 Time: 1000 Ethnicity: White Age: 11 years old Sex : Male SUBJECTIVE (must complete this section) CC : ADHD Evaluation HPI : Mom of the patient reports the patient has been struggling with focusing and attention. Mom states that they have noticed this since the patient was in first grade, but they were trying other methods first such as reorientation, incentives, charts, planners, and other methods to help her son focus on school. Mom states that the teacher has been calling weekly now stating they he is unable to focus on school and that she constantly must draw her son back in the class as he is spacing out. Mom states that her son is unable to complete his schoolwork at school and then comes home with 2 hours’ worth of schoolwork that he should have been able to complete in school but was unable to. Mom states that they have been having some trouble at home with him following multi step directions as well and needs constant reminders. Medications : N/A Previous Medical History: Developmental History: Developed appropriately. Allergies: NKDA Medication Intolerances: None Chronic Illnesses/Major traumas: None Immunizations: Up to date Hospitalizations/Surgeries: None Health Promotion/Health Maintenance: Appropriate for age Nutrition/Diet: Exercise/Regimen: appropriate for age Tobacco/Alcohol/Vaping/Illicit Drug Use or Exposure: N/A Safety Measures: Screening exams: F AMILY HISTORY (must complete this section) M: Livin g, healt hy HTN MGM : Livin g with brea st canc er MGF F : PGM: PGF Social History: Patient is a healthy eleven-year-old boy. Mom reports that he goes to third grade and gets along well with his classmates. No developmental or social concerns. REVIEW OF SYSTEMS (must complete this section) General : No fever or chills. Appears in no acute distress Cardiovascular : denies having palpitations and chest pain. Skin : No rashes lumps or bruises Respiratory: Denies any shortness of breath or difficulty in breathing

C ONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Note s 11202 3 Page 2 of 4 Eyes : Denies change in vision or drainage from eye Gastrointestinal: denies experiencing hematemesis, diarrhea, constipation, nausea, vomiting, or abdominal discomfort . Ears : Denies any ear pain, tinnitus, or hearing loss Genitourinary/Gynecological: Denies any abdominal pain, nausea, vomiting, or any problems urianting Nose/Mouth/Throat. denies congestion, odynophagia, sinus discomfort, running nose, and epistaxis. Recognizes sore throat. Musculoskeletal: denies any swelling or joint pain Breast: Deferred. Neurological : denies experiencing seizures, syncope, disorientation, headaches, neck discomfort, or weakness. Heme/Lymph/Endo: denies polyphagia, polyuria, polydipsia, and weight loss denies having anemia, petechiae, purpura, and heavy bleeding. Psychiatric : Denies any confusion OBJECTIVE (Document PERTINENT systems only, Minimum 3) Weight : 90 lb Height : 53 in BMI : 22.4 BP: 98/50 Temp : 98.0 Pulse: 90 Resp : 21 SPO2 %: 100% General Appearance: Pt appears fidgeting in his chair and looking around the room as mom is talking Skin : No rashes, lumps or bruises noted on the body HEENT Cardiovascular: Regular rate and rhythm Respiratory : No adventincious lung sounds. No dyspnea noted on exam . Gastrointestinal: No abdominal tenderness Breast : Genitourinary : Musculoskeletal: Neurological: Psychiatric : Pt appears fidgety and moving all around the room. Diagnostic N/A Special Tests: NICHQ Assessment form filled out by parents, child, and teacher DIAGNOSIS (Minimum required differential and presumptive dx's, can do more) Differential Diagnoses  Diagnosis, (ICD 10 code and reference): attention deficit disorder F90.0 A long-term illness characterized by impulsivity, hyperactivity, and trouble focusing. ADHD can last until adulthood and frequently starts in infancy. Low self- esteem, strained relationships, and difficulties at work or school could all be caused by it. Hyperactivity and poor attention span are among the symptoms (O’Hara et al., 2020).  Diagnosis, (ICD 10 code and reference): Dysthymic Disorder F34.1 A poor mood that lasts for at least two years combined with at least two other depressive symptoms is known as dysthymia. A few symptoms are despondency, low self-esteem, reduced appetite, low energy, irregular sleep patterns, and difficulty concentrating (Schramm et al., 2020).  Diagnosis, (ICD 10 code and reference): Sleep wake disorder G47.23 Problems with the quantity, timing, and quality of sleep are referred to as sleep disorders (or sleep-wake disorders) and can cause distress and functional impairment during the day (“Circadian Rhythm Sleep– Diagnosis  Presumptive diagnosis (ICD 10 code and reference): Attention deficit disorder F90.0

C ONPH NSG6435 Subjective, Objective, Assessment, Plan 11202 3 Page 4 of 4 Psychiatry , 7 (9), 801–812. https://doi.org/10.1016/S2215-0366(20)30099-7