Assignment 2: Focused SOAP Note and Patient Case Presentation To Prepare Review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded
This study source was downloaded by 100000794395091 from CourseHero.com on 10-26-2022 23:09:25 GMT -05:00https://www.coursehero.com/file/94345132/WK9Assgn2bowlinghPRAC6665docx/ Week 9: Focused SOAP Note and Comprehensive Assessment
Holly Bowling
College of Nursing-PMHNP, Walden University
PRAC 6665: PMHNP Care Across the Lifespan I Practicum
Latanya Battle-Wherry
May 3, 2021 This study source was downloaded by 100000794395091 from CourseHero.com on 10-26-2022 23:09:25 GMT -05:00
https://www.coursehero.com/file/94345132/WK9Assgn2bowlinghPRAC6665docx/Subjective:
CC : Parents are seeking a second opinion for a possible misdiagnosis of ADHD and OCD, and a
possible diagnosis of Autism.
HPI: This is a 10-year-old Caucasian male who presents with his parents for being easily
distracted, inability to wait his turn in lines, very fidgety, and always wanting to get out of his
seat. The parents explain that he has had these compulsive and rigid behaviors since a young
child, but they have become more worse as he has gotten older. He likes the same routine always,
and does not like changes, and gets very upset if his mother makes any change in his daily
routine. Specific changes include, if his mother takes a different route to school, or if rules are
not followed exactly as they should be at school. His parents endorse that instead of playing with
toys, he takes them apart. He does not interact well with other kids at school and does not know
how to act when they try to talk or play with him. He has issues with sharing or taking turns.
They endorse that during his first year of life he would not smile at them or babble, or even make
eye contact with them, and had limited expressions. They stated that he was different from his
siblings in the fact that he was harder to read because he did not express his emotions like the
other two children. He was not interested in normal games and activities like his siblings, such as
dress-up or imagination games. They said he has never been one to seek praise when he has an
accomplishment. And he shows no empathy or effort to comfort his friends when they would get
hurt or seem upset. At the age of five, they said he became more aggressive toward people if they
would try to invade his space, and he has not interested in engaging in play, or conversation, or
even games with kids his age, and that he usually stays to himself. His parents endorse his
behavioral symptoms of aggression and agitation have become worse as he gets older, and he
frequently gets suspended. His behaviors seem to be worse when he is in a loud environment,
such as the playground or places where there are a lot of people. He has been noted to have an
average IQ with superior to gifted abilities in information and block design. He greets people by
asking them questions about cars and provides them with detailed information about specific
makes and models, however, he has issues responding to people or making eye contact. Because
of his high cognitive abilities and behavior issues, he was placed in an alternative program ,
however, he is not succeeding because he is being treated as if he has ADHD with disruptive
behaviors.
Substance Current Use: Denies. No family history. No abuse or neglect.
Medical History: One neurologist noted clumsiness, difficulties holding a pencil correctly, and
poor handwriting. Otherwise, no medical history.
Current Medications : He has been trialed on Clonidine, Stimulants, and Paroxetine but they all
had unpleasant side effects and none of them worked for him. Denies taking any current
medications. This study source was downloaded by 100000794395091 from CourseHero.com on 10-26-2022 23:09:25 GMT -05:00
https://www.coursehero.com/file/94345132/WK9Assgn2bowlinghPRAC6665docx/Allergies : Denies
Reproductive Hx : Carried full term without any issues; met all developmental milestones
ROS :
GENERAL: Well-appearing, alert, withdrawn, non-interactive; no changes in weight; no
fevers, chills, weakness, or fatigue
HEENT: No hearing changes, ear pain, or nasal congestion
SKIN: No lesions, pruritis, or hair changes
CARDIOVASCULAR: No CP, SOB, or cough
RESPIRATORY: No cough, sputum, wheezing, dyspnea, or smoke exposure
GASTROINTESTINAL: No N/V/D, no changes in weight or appetite
GENITOURINARY: No pain with urination, blood in urine, or changes in color
NEUROLOGICAL: No numbness, weakness, or paresthesia
PSYCHOLOGICAL: No eating concerns, delusions, rumination, SI/HI/AH/VH, or
personality changes. Provides minimal eye contact or information when asking questions.
MUSCULOSKELETAL: No muscle or joint pain, or stiffness
HEMATOLOGIC: No bruising, bleeding, or transfusion history
LYMPHATICS: No enlarged lymph nodes
ENDOCRINOLOGIC: No increased sweating or heat or cold intolerance; no
polyuria/polydipsia
Objective: The client presents with a restricted mood; however, no other physical abnormalities
were noted that relate to the client's diagnosis.
Diagnostic results : There is no single test that is diagnostic of autism. To have a diagnosis of
Autism, an individual must satisfy the diagnostic criteria outlined in the DSM-5. The basic triad
of impairments underlying Autism has included impairment of social interaction, impairment of
communication, and restricted repetitive and stereotyped patterns of behavior (Association For
Science in Autism Treatment (ASAT), 2020). This client’s history of marked social
communication deficits, isolation, and restricted interests is consistent with the DSM-5 diagnosis
of ASD. Additional standardized instruments that are often utilized for ASD include The
Childhood Autism Rating Scale (CARS), The Gilliam Autism Rating Scale (GARS), or a
combination of the Autism Diagnostic Interview-Revised (ADI-R) and the Autism Diagnostic
Observation Schedule (ADOS) (ASAT, 2020). A medical evaluation is recommended to This study source was downloaded by 100000794395091 from CourseHero.com on 10-26-2022 23:09:25 GMT -05:00
https://www.coursehero.com/file/94345132/WK9Assgn2bowlinghPRAC6665docx/determine if there is a specific, diagnosable medical condition that is associated with autistic
behaviors or whether there are medical conditions commonly associated with autism, such as
seizure disorder, that require further evaluation and treatment. An audiological evaluation is
always an important aspect of the comprehensive assessment (ASAT, 2020). According to the
information provided by his parents, there is no other diagnosable medical condition that would
be associated with his manifestations.
Assessment:
Mental Status Examination : This is a 10-year-old Caucasian male who looks age stated ,
appearance is neat and clean, and dressed appropriately. He is restless and fidgety during the
interview. He did not answer questions directed toward him but instead would ask the
interviewer about specific cars. Upon response to the client's question, he then proceeded to list
vehicle designs and comment the interviewer on her voice. Talking about cars, seemed to open
the client up, and his tone became more expressive, and eye contact more engaged. He knew he
did not make friends but was unsure of why. Unable to assess mood accurately due to limited
facial expressions and inability to describe his feelings. He denies SI, HI, hearing or seeing
things, or any kind of hallucinations. Denies sleep or issues with appetite.
Diagnostic Impression:
Autism Spectrum Disorder (ASD) (F84.0)- To diagnose ASD, all of the five criteria
must be met including social communication deficits, fixated interests, and repetitive
behaviors consisting of four items including stereotyped or repetitive motor movements,
insistence on sameness, highly restricted, fixated interests that are abnormal in intensity
or focus, and hyper or hypo reactivity to sensory input or unusual interests in sensory
aspects of the environment, of which at least two must be met to satisfy this criterion;
symptoms existing in early childhood; symptoms impairing functioning; and impairments
are not better explained by intellectual disability or global developmental delay (APA,
2013). Based on the evidence of his persistent difficulties in social interaction and
communication, as well as the restricted patterns of behavior that have been presenting
from an early age, including his consistent daily routines and inability to change them,
his lack of eye contact and smiling, his non-verbal behaviors, his inability to form
relationships, his fixation on cars, the disturbances cause clinically significant
impairment in social functioning, as evidenced by his pronounced difficulties in social
interaction, absence of friendships, aggression, oppositional behaviors, and inflexibility
and/or rage in response to changes in routines, and the fact that he does not have a history
of clinically significant delay in language development, cognitive development, or
acquisition of other adaptive behaviors, provides enough criteria and makes the diagnosis
of ASD justifiable.
ADHD Combined (F90.2)- According to the DSM-5, a diagnosis of ADHD is defined as
the presence of six or more specific symptoms occurring for at least six months of either
inattention, hyperactivity, or both (APA, 2013). Specific issues that can be seen with
ADHD include poor performance in school, behavioral problems, difficulty expressing
feelings or building relationships, and the inability to think correctly (Krull, 2019). This study source was downloaded by 100000794395091 from CourseHero.com on 10-26-2022 23:09:25 GMT -05:00
https://www.coursehero.com/file/94345132/WK9Assgn2bowlinghPRAC6665docx/Hyperactivity, impulsiveness, inattention are not typical core features of ASD, however,
they are common in this clinical presentation and are justifiable manifestations for a
second diagnosis of ADHD.
Social Communication Disorder (SCD) (F80.89)- Shows deficits in social
communication but also demonstrates an absence of interest in social communication and
social-emotional reciprocity, impairment of the ability to change communication to
match context or the needs of the listener, difficulties following rules during a
conversation, and difficulties making inferences ( Mandy, Wang, Lee, & Skuse, 2017). ).
The differentiation between SCD and ASD is that ASD presents with highly restricted
interests, insistence on sameness, and inflexible adherence to routines. Therefore, since
the client is shown to have a history of presenting manifestations, a diagnosis of SCD can
be ruled out.
Obsessive-Compulsive Disorder (OCD)- OCD is a common, chronic, and long-lasting
disorder in which a person has uncontrollable, reoccurring thoughts and/or behaviors that
he or she feels the urge to repeat over and over (NIMH, 2019). Diagnostic criteria include
the presence of obsessions, compulsions, or both, and they are time-consuming or cause
significant impairment in social functioning. They must not be attributed to the effects of
another substance or better explained by another mental disorder (APA, 2013). The
clinical picture is not consistent with that OCD, although his preoccupation with cars may
be considered obsessive, it is not an obsessional concern. Children with OCD typically
describe the intrusion of unwanted thoughts that are difficult to dislodge, however, this
client likes to think and talk about cars all the time. His reoccurring thoughts and
insistence on routines are better justified as ASD than OCD.
Reflections: The main thing I learned while doing this case study was that there are many
symptoms of ASD that manifest as other disorders such as OCD, ADHD, social communication
disorder, as well as many others. Therefore, it is important to get as much information as possible
before making a definitive diagnosis to come up with the best treatment plan specific for each
patient. Symptoms of ASD usually manifest at an early age, however many parents don’t realize
there is an issue until sometimes years later. Therefore, it is important to educate parents on
symptoms associated with ASD and to start early interventions to have the best possible
outcome. Overall, there is not much I would change about the way this client was treated. The
only thing I might change or do different would be to have the parents and teachers fill out the
ABC before seeing the client, that way we would have had a better idea of how serious his
symptoms were, and could have started medication treatment right away if needed.
Case Formulation and Treatment Plan : This is a 10-year-old Caucasian boy, who lives with
his parents, an older sister, and a younger brother, and presents with his parents who are seeking
a second opinion about their sons’ diagnoses of attention-deficit/ hyperactivity disorder (ADHD)
and obsessive-compulsive disorder (OCD). They endorse odd behaviors since 12 months of age,
such as not making eye contact and absence of appropriate nonverbal behaviors. Upon doing
their own investigation, they have some new insight regarding possible causes for their son’s
behavioral issues. He has unusual manifestations of, ritualistic behaviors, lack of interest in play,
or other children, lack of participation in social groups, he doesn’t share or take turns, and This study source was downloaded by 100000794395091 from CourseHero.com on 10-26-2022 23:09:25 GMT -05:00
https://www.coursehero.com/file/94345132/WK9Assgn2bowlinghPRAC6665docx/insensitivity to social patterns. The main focus of treatment for this client will be educational and
behavioral therapy. Medication options are generally used to target behaviors, such as irritability,
hyperactivity, anxiety, and repetitive behavior, rather than the social disability of ASD. He needs
to be placed in a special education class that is least restrictive and in an appropriate setting
(Autism Society, 2020). The focus of his class should be on his social disability, which is central
to ASD. He needs something that will promote social skills, such as communication techniques,
greeting people, initiating games, and joint attention, as his social disability is interfering with
his overall academic success (Sadock, Sadock, & Ruiz, 2015). This client will benefit from
behavioral therapy that focuses on specific maladaptive behavior, such as aggression, as well as
specific skills-building, such as his language or everyday living skills. Behavioral therapy has
been shown to reduce aggression and self-injurious behaviors and is considered the gold
standard of treatment for behavioral problems related to ASD (Maneeton, Maneeton, Putthisri,
Woottiluk, Narkpongphun, & Srisurapanont, 2018). Parent behavioral training will also be
beneficial in helping the parents to improve his behavior in the home and the community. We
will have his parents and teachers fill out an Abberent Behavior Checklist (ABC) which will
help in identifying target symptoms. We will hold off on medication treatment until he can
establish an individualized education program (IEP), hopefully, in a timely manner ( Schmidt,
Huete, Fodstad, Chin, & Kurtz, 2013). However, if this process is prolonged, then it will be
important to consider medication management to target his hyperactivity, such as
Methylphenidate, as it has been shown to be beneficial in targeting hyperactivity in those
diagnosed with ASD ( Sturman, Deckx, & Van Driel, 2017). Risperidone is another drug that is
FDA approved for the use of irritability and has been proven to be effective in reducing
irritability and hyperactivity in those diagnosed with ASD (Maneeton et al., 2018). Depending
on the outcome of the ABC checklist and the timely manner of the IEP, Methylphenidate, and
Risperidone will both be beneficial options for medication management. Self-management
techniques will also be beneficial for this client as they work by targeting a specific behavior and
teach the client to identify an occurrence of the behavior while recording, evaluating, and then
self-reinforcing. Self-management can help with controlling his excessive motor activity, help
him learn to follow directions, reduce his rituals, as well as learning more appropriate social
approaches (Schulze, 2016). The client is to follow up in one month and depending on the ABC
checklist, IEP, and client symptoms, we will decide whether or not to add in medication
treatment. Many individuals with ASD have issues with sleeping, as well as a higher incidence
of gastrointestinal issues. It is important to teach them good sleep hygiene, such as providing a
good sleep environment and a normal bedtime routine, as well as appropriate foods and
medications to help with gastrointestinal symptoms, such as belching, constipation, and diarrhea
(Sadock et al., 2015). Some alternative approaches that might be utilized include music therapy
to promote communication and expression, and yoga to promote attention and decrease activity
level (Sadock et al., 2015). This study source was downloaded by 100000794395091 from CourseHero.com on 10-26-2022 23:09:25 GMT -05:00
https://www.coursehero.com/file/94345132/WK9Assgn2bowlinghPRAC6665docx/References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author.
Association For Science In Autism Treatment (ASAT). (2020). Autism diagnosis. Retrieved from
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Heb9GXoj7xhoCr-oQAvD_BwE
Autism Society. (2020). Academic success. Retrieved from https://www.autism-
society.org/living-with-autism/academic-success/
Krull, K. (2019). Attention deficit hyperactivity disorder in children and adolescents: Clinical
features and diagnosis. Retrieved from https://www.uptodate.com/contents/attention-
deficit-hyperactivity-disorder-in-children-and-adolescents-clinical-features-and-diagnosis
Maneeton, N., Maneeton, B., Putthisri, S., Woottiluk, P., Narkpongphun, A., & Srisurapanont, M.
(2018). Risperidone for children and adolescents with autism spectrum disorder: a This study source was downloaded by 100000794395091 from CourseHero.com on 10-26-2022 23:09:25 GMT -05:00
https://www.coursehero.com/file/94345132/WK9Assgn2bowlinghPRAC6665docx/systematic review. Neuropsychiatric disease and treatment , 14 , 1811–1820.
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