This article provides a sample solution to Initial Psychiatric Interview/SOAP Note.
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Initial Psychiatric Interview/SOAP Note
Informed Consent
Informed consent is given to the patient about the psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. The patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion)
Subjective
Verify Patient
Name: #Name
DOB: 01/01/20XX
Minor: yes
Accompanied by: Father
Demographic: 6yo, single African American female, younger of two children, daycare
Gender Identifier Note: NA
CC: Father States, “My daughter is prone to making careless mistakes at home, school work and other activities.”
HPI: (per Dad) the patient is a six-year-old female child who exhibits hyperactivity, inattentiveness, and impulsivity that started seven weeks ago and continues to increase in intensity. These manifestations are not associated with difficulties in the child understanding instructions. The father also reports that the daughter is not defiant while observing these symptoms at any time of the day. If reprimanded, the symptoms are momentarily relieved. The father reports that her teacher has informed him of the child’s symptoms three times previously. He opines he decided to bring the child for psychiatric assessment since talking to the child and commensurate punishment appears not to tame the child’s unbecoming behavior. The father adds that the child has exhibited these behaviors since the age of three years and was hopeful it was a developmental milestone that would resolve independently.
Pertinent History in the record and from the patient: NA
During assessment: Patient constantly fidgets with hands/feet, appears easily distracted and frequently interrupts even when not being addressed. Father reports the child exhibits increased activity, denies the child is agitated or displays risk-taking behaviors. He also observes that the child does not have pressured speech and is negative for excessive fears, worries and panic disorders.
Allergies: She has rashes, hives, and itchy eyes if penicillin-based medication is administered to her.
Past Medical Hx: BK had a pneumonia attack at three years of age which had her hospitalized for five days. She received BCG, DPT, and measles vaccines (2016-2016), Influenza vaccine (2018) and pneumonia 2017. The child has not suffered any head injury or trauma. The patient has a history of Malaria that was successfully treated using combination therapy as an outpatient. The patient has no history of meningitis.
Medical History: Father denies cardiac, respiratory, endocrine and neurological issues, including a History of head injury. Father reports negative chronic infection, including MRSA, TB, HIV and Hepatitis C. Surgical History no surgical history reported
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Past Psychiatric Hx:
Previous psychiatric diagnoses: Not disclosed.
Previous medication trials: Not disclosed.
Safety concerns:
History of Violence to Self: Not disclosed
History of Violence to Others: Not disclosed
Auditory Hallucinations: Not disclosed
Visual Hallucinations: Not disclosed
Mental health treatment history discussed:
History of outpatient treatment: None disclosed
Previous psychiatric hospitalizations: None disclosed
Prior substance abuse treatment: None disclosed
Trauma history: Mom Father does not report a history of trauma, including abuse, domestic violence, witnessing disturbing events.
Substance Use: Father reports negative use or dependence on nicotine/tobacco products. Father does not report the abuse of or dependence on illicit drugs.
Current Medications: No current medications.
Past Psych Med Trials: None
Family Medical Hx: No family member- parents, sibling or grandparents have a significant medical history pertinent to the case -except paternal uncle was diagnosed with ADHD
that was successfully treated through behavior therapy.
Family Psychiatric Hx:
Substance use: none reported
Suicides: None reported
Psychiatric diagnoses/hospitalization: none reported
Developmental diagnoses: none reported
Social History:
The girl is second born in a family of 2. The elder sibling is a boy aged ten who has no medical or mental problems to date.
Education history: daycare
Developmental History: Father Reports wife had no problems with pregnancy; denies use of illicit drugs, alcohol or tobacco; BK was delivered at 39 ½ weeks gestation; Apgar scores 9 and 10; 7 lbs 9 oz, 20 ½ inches long
Developmental Milestones: Father Reports there have been no concerns with the patient meeting/achieving anticipated developmental milestones; for example, BK walked at 9 ½ months of age.
Legal History: no reported/known legal issues, no reported/known conservator or guardian.
Spiritual/Cultural Considerations: none reported.
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ROS: Chief informant –Father
Constitutional: No report of fever or weight loss, no sleep issues. However, the father reports excessive hyperactivity, impulsivity, and inattentiveness not accompanied by issues of understanding.
Eyes:
Negative for acute vision changes or pain in the eyes.
ENT: Negative hearing changes or difficulty swallowing. No hoarseness in voice
Cardiac: The child does not have chest pain, edema or orthopnea or other chest discomforts.
Respiratory: Negative for dyspnea, cough or wheeze. Reports the child has the occasional “cold.”
GI: Father admits BK reports occasional c/o “stomach aches”, but the aches are not accompanied by a change in appetite, No N/V/D
GU: Negative of dysuria or hematuria. No bed-wetting
Musculoskeletal: Negative of joint pain or swelling.
Skin: Negative of rashes, lesions, abrasions.
Neurologic: Negative of seizures, blackout, numbness or focal weakness.
Endocrine: No report of polyuria or polydipsia.
Hematologic: No report of blood clots or easy bleeding.
Allergy: Affirmative for penicillin allergy has hives or itchy eyes as allergic reaction, upon penicillin-based medication administration.
Reproductive: No report of significant issues
Objective
Vital Signs: Stable
Temp: 98.4 BP:113/71 HR:64 R:16 O2:NA Pain: NA Ht:47inches Wt:49 lbs BMI: 17.5
LABS:
Lab findings NA
Tox screen: NA
Alcohol: NA
HCG: N/A
Physical Exam:
Hearing: can hear a whisper test, intact at 5 feet
Vision: via Snellen chart, 20/30 bilateral
General: attire appropriate for the occasion, responds to and interacts with the interviewer well.
Skin: Warm, dry and intact.
HEENT: normocephalic; PERRLA; no discharge noted eyes or ears; TMs shiny and grey bilateral; nares patent without discharge noted; oral cavity pink with moist mucus membranes, mild tonsillar enlargement without erythema
Neck: Negative for lymphadenopathy noted on palpation
CV: regular rhythm, S1and S2 sounds without murmur, radial and pedal pulses palpable
Respiratory: Lungs clear to auscultation
GI: Negative for organomegaly, abdomen soft, non-tender with active bowel sounds all four quadrants,
MSK: no significant abnormalities present
Neuro: Remainsalert and responsive throughout the interview
Psych: fidgeting with hands and feet during the encounter gets easily distracted by minor noises and interrupts the provider and father throughout the visit
MSE:
Two approaches were made where the child was observed in various settings and secondly during the interview session. The History given by the father about the child’s symptoms helped the clinician to set up the clinical situations for assessment. While in the waiting area, the child could be heard talking; she was shouting or making sounds loudly as she moved chairs while running to and fro. Efforts by the father to make BK remain still and be quiet were fruitless. She only stopped momentarily. When both were invited into the interview room, the child rushes in and appears to have difficulties waiting or keeping behind.
Once in the room, she jumps into a chair while in its twists, turns, wiggles, and slides both forward and backwards. When the father is asked a question, BK replies before him. She responds to questions about school before the questions are complete. She frequently interrupted the father when it was his turn to respond to questions.
After some minutes, the child’s fear of the clinical setting disappears, and she quickly appeared bored. As time progressed, the child began to lose interest and became inattentive.
Father has the capacity to articulate needs, is motivated for compliance and adherence to the medication regimen. The parent is also willing to involve his wife and participate in behavioral therapy treatment, disposition, and care planning.
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Assessment
DSM5 Diagnosis: with ICD-10 codes
Dx: 1- ADHD, combined type (F90.2)- Confirmed
The child was diagnosed with ADHD because upon assessment for hyperactivity and impulsivity, and she should be heard and seen talking, shouting, and making sounds loudly. Her moving chairs and running to and from were persistent despite her father insisting she remains still and be quiet. Impulsivity was evident as the child had challenges waiting for her turn (Belanger et al., 2018). While it is more difficult to assess for the inattentiveness, the child seemed to lose interest with the interview questions within 20 minutes into the interview session, although she kept interrupting her father sometimes throughout the interview. The physical exam and lab results helped to rule out organic or physiological causes for any of the symptoms she exhibited.
Dx2: – Social Anxiety Disorder (DSM-5 Code of 300.23(F40.10)- Refuted
Symptoms of ADHD may overlap with those of SAD. Some of the manifestations of SAD are increased anxiety if the child is separated from a parent and maybe accompanied with panic experience reaction like shaking, sweating or shortness of breath (Vallance & Fernandez, 2016). The pediatric patient did not exhibit any of these symptoms or even tantrums and crying; hence it was considered highly unlikely.
Dx3: – Autism Spectrum Disorder (ASD) –F84.0 –Refuted
ASD is a condition that affects the development of the brain in childhood, as does ADHD. Children with either or both conditions can focus on one thing, but the presence of ASD is identifiable in that the child tends to avoid eye contact and may not want to play with other children (Parmeggiani et al., 2016). Other symptoms that helped rule out ASD id that according to the Chief Informant(father), BK had not experienced difficulties is any development milestone speech inclusive. As such, this disorder was also refuted.
Father 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 adherence. Reviewed potential risks & benefits, Black Box warnings, and alternatives, including declining treatment.
Plan
Safety Risk/Plan: The patient does not pose any significance to herself or others at this point.
Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic:
No medications are recommended at this time.
- Psychotherapy referral for CBT
- Behavior therapy recommended
Education, including health promotion, maintenance, and psychosocial needs
- Importance of medication if behavioral therapy appears not to be wielding desirable results
- Lifestyle modifications to include: diet, exercise, sleep.
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Referrals: Therapist for CBT
Follow-up, including a return to the clinic (RTC) with time frame and reason and any labs that are needed for the next visit four week
Plan:
- Attention-deficit hyperactivity disorder, combined type (F90.2)- Non Pharmacological interventions only
- Behavior Therapy
- Lifestyle Changes: Diet
- Exercise
- Sleep
- Attention-deficit/hyperactivity disorder (ADHD) causes hyperactivity, impulsiveness, and attention problems. Behavior therapy can improve ADHD symptoms without the use of medicine. Clinical guidelines recommend that healthcare providers first refer parents for training in behavior therapy before prescribing medicine (Keilow et al., 2018).
- Butterworth & Kovas(2013) suggest that the first treatment line for children aged 4-5 is to prescribe evidence-based parent and teacher-administered behavior therapy. Pharmacological interventions should be considered only if behavioral therapy does not improve the child’s behaviors over time, say between 3 to 6months. Vyvanse is not used for children under the age of 5 and should not be prescribed at this time until behavioural therapy is tried. The parents should be educated on environmental factors that can affect children with ADHD. Lifestyle modifications comprising of changes in diet, exercise, and regular sleep patterns should be integrated. Exercises should involve active contact sports like football or basketball, while a diet rich in Zinc, Omega-3 fatty acids and Vitamin D should be in plenty. Stimulants like caffeine should be avoided.
References
Bélanger, S. A., Andrews, D., Gray, C., & Korczak, D. (2018). ADHD in children and youth: part 1—aetiology, diagnosis, and comorbidity. Paediatrics & child health, 23(7), 447-453.
Keilow, M., Holm, A., & Fallesen, P. (2018). Medical treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) and children’s academic performance. PloS one, 13(11), e0207905.
Butterworth, B., & Kovas, Y. (2013). Understanding neurocognitive developmental disorders can improve education for all. Science, 340(6130), 300-305.
Vallance, A. K., & Fernandez, V. (2016). Anxiety disorders in children and adolescents: Aetiology, diagnosis and treatment. BJPsych Advances, 22(5), 335-344.
Parmeggiani, A., Corinaldesi, A., & Posar, A. (2019). Early features of autism spectrum disorder: a cross-sectional study. Italian journal of paediatrics, 45(1), 1-8.
