ASSIGNMENT: EPISODIC VISIT: ADOLESCENT FOCUSED NOTE (AGES 13-17)

ASSIGNMENT: EPISODIC VISIT: ADOLESCENT FOCUSED NOTE (AGES 13-17)

ASSIGNMENT: EPISODIC VISIT: ADOLESCENT FOCUSED NOTE (AGES 13-17)

Episodic/Focused SOAP Note Template

Patient Information:
AB, 12 years, Male, White American
S.
CC (chief complaint): “Medication refill”
HPI: AB is a 13-year-old male patient whose mother brought him to the facility for a medication refill. The patient has a history of attention deficit hyperactivity disorder (ADHD). He has been on treatment. Today, his mother brought him for a dexmethylphenidate 25 mg q24 refill. AB reported that he has been tolerating the medication well. He noted the medication has been effective in managing ADHD symptoms. The mother reported sustained improvements in AB’s social and academic functioning. AB denied any concerns during this visit.

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Current Medications: AB currently uses oral dexymethylphenidate 25 mg q24. He denies the use of other medications.
Allergies: AB reported an allergic reaction to animal dander and pollen. He denied food or drug allergies.
PMHx: AB was diagnosed with ADHD at the age of 10 years. He denied any history of chronic illness, hospitalization, or surgery. AB’s immunization record is up-to-date.
Soc & Substance Hx: AB is a student. He does not smoke or take alcohol. He lives with his parents in a rented apartment. He is the second born in a family of two. AB’s hobbies include drawing and spending time with his brother. AB has not learned how to ride a bicycle. Their home has smoke detectors.
Fam Hx: AB’s father has hypertension. His parental grandfather has hypertension and diabetes. AB’s maternal grandmother died of cervical cancer.
Surgical Hx: AB has no history of surgery.
Mental Hx: AB was diagnosed with ADHD at the age of 10 years. He has no other history of psychiatric diagnoses. He currently uses oral dexymethylphenidate 25 mg q24.
Violence Hx: AB denied concerns about violence.
Reproductive Hx: AB denied urgency, frequency, or dysuria.
ROS:
GENERAL: AB was dressed appropriately for the clinical visit. He denied fevers, chills, or fatigue.
HEENT: Eyes: AB was not wearing corrective lenses. He denied eye pain, discharge, or blurred vision. Ears, Nose, Throat: AB denied ear pain, fullness, or ringing in the ears. He also denied nasal fullness, drainage, or painful swallowing.
SKIN: AB denied skin rashes.
CARDIOVASCULAR: AB denies chest pain, discomfort, or palpitations.
RESPIRATORY: AB denied cough or shortness of breath.
GASTROINTESTINAL: AB denies nausea, vomiting, diarrhea, or abdominal pain.
GENITOURINARY: AB denied urgency, frequency, or dysuria.
NEUROLOGICAL: AB denied headaches, dizziness, loss of bladder or bowel control, or paralysis.
MUSCULOSKELETAL: AB denied muscle or joint pain, joint swelling, or non-weight bearing on joints.
HEMATOLOGIC: AB denied anemia or easy bruising.
LYMPHATICS: There was no splenectomy or lymphadenopathy.
PSYCHIATRIC: AB has a history of ADHD.
ENDOCRINOLOGIC: AB denied weight changes, and cold or heat intolerance.
REPRODUCTIVE: AB denied urinary urgency, frequency, or dysuria.
ALLERGIES: AB reported allergic reactions to animal dander and pollen.
O.
Physical exam:
Respiratory: There is no nasal flaring, cough, sputum, crackles, or wheezes on auscultation
Cardiovascular: There are S1 and S2 heart sounds. There is no peripheral edema, S3, or S4 heart sounds.
Diagnostic results: none
A.
Differential Diagnoses
ADHD that is responsive to treatment (ICD 10: F90.9): AB has ADHD that is responsive to treatment. ADHD is a mental health disorder characterized by symptoms, including inattention, hyperactivity, and impulsivity. The symptoms of inattention that patients demonstrate often include not being attentive, making careless mistakes, difficulties in maintaining attention, not listening when being spoken to directly, not following instructions, being disorganized, and having easy distractibility. The symptoms of hyperactivity and impulsivity include fidgeting, difficulty remaining seated, unable to participate in leisure activities, talkativeness, and interrupting others (Cabral et al., 2020; Chang et al., 2020). AB has a history of ADHD. He has been on treatment. He reports that he tolerated treatment. The treatment has been managing well his ADHD symptoms, hence, it being the primary diagnosis.
Generalized anxiety disorder (ICD 10L F 41.1): Generalized anxiety disorder is the other diagnosis that the provider should rule out in AB’s case. ADHD often coexists with other mental health disorders, including generalized anxiety disorder. Patients with generalized anxiety disorder experience symptoms such as excessive fear and worry beyond their control. The accompanying symptoms include restlessness, fatigue, and difficulty concentrating, irritability, and muscle tension (Showraki et al., 2020). AB denies these symptoms; hence, generalized anxiety disorder is his least likely diagnosis.
Major depression (ICD 10: F321): Major depression is the other differential diagnosis that should be considered in AB’s case study. Major depression is a mood disorder characterized by a persistently depressed mood. Patients report additional symptoms such as fatigue, hopelessness, guilt, difficulty concentrating and making decisions, changes in sleep patterns, weight, and appetite, and suicidal thoughts, plans, or attempts (Rybak et al., 2021). Major depression can be a coexisting comorbidity in ADHD patients. However, AB denied a depressed mood, which makes major depression the least likely diagnosis.
P.
No diagnostic studies will be obtained for AB during this study. Similarly, no referrals will be made to other healthcare providers since AB is responding well to treatment. AB and his mother were educated on the importance of treatment adherence, side effects, healthy lifestyles and behaviors, and ensuring that AB’s immunization records were up-to-date. A follow-up visit was scheduled after four weeks to assess AB’s response to treatment. I agree with my preceptor’s diagnosis of ADHD which is responsive to treatment. AB denied any side effects associated with the current treatment. He also expressed that methylphenidate was effective in managing ADHD symptoms. I will assess the patient for other coexisting comorbidities such as generalized anxiety disorder and obsessive-compulsive disorder should I encounter this patient again. I learned from this case the importance of using evidence-based interventions in managing mental health problems. Evidence-based interventions optimize outcomes such as the management of symptoms of mental health problems (Cabral et al., 2020). The FDA has approved methylphenidate for use in ADHD in children. Methylphenidate selection for AB’s treatment has been effective.

References
Cabral, M. D. I., Liu, S., & Soares, N. (2020). Attention-deficit/hyperactivity disorder: Diagnostic criteria, epidemiology, risk factors and evaluation in youth. Translational Pediatrics, 9(Suppl 1), S104–S113. https://doi.org/10.21037/tp.2019.09.08
Chang, J. G., Cimino, F. M., & Gossa, W. (2020). ADHD in Children: Common Questions and Answers. American Family Physician, 102(9), 592–602.
Rybak, Y. E., Lai, K. S. P., Ramasubbu, R., Vila-Rodriguez, F., Blumberger, D. M., Chan, P., Delva, N., Giacobbe, P., Gosselin, C., Kennedy, S. H., Iskandar, H., McInerney, S., Ravitz, P., Sharma, V., Zaretsky, A., & Burhan, A. M. (2021). Treatment-resistant major depressive disorder: Canadian expert consensus on definition and assessment. Depression and Anxiety, 38(4), 456–467. https://doi.org/10.1002/da.23135
Showraki, M., Showraki, T., & Brown, K. (2020). Generalized Anxiety Disorder: Revisited. Psychiatric Quarterly, 91(3), 905–914. https://doi.org/10.1007/s11126-020-09747-0

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Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.

Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?

Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.

Reflection notes: What was your “aha” moment? What would you do differently in a similar

Patient Information:
Client Information Site Office
Age 10–12 years
Gender Male
Visit Information Student Level of Function Intense supervision – Level 1
Category of Care Direct Patient Care
Practice Management Type of visit/phys. exam Chronic office – 99212
Diagnosis 1 ADHD
Student Notes
12 y/o male patient came in for dexmethylphenidate 25mg q24 for refill. The patient has been tolerating the medication well and reports no side effects and states that the medication is managing ADHD symptoms well.

Templet and guide attached below addtional patient information came be made up. Templete must be used.