Respond at least 2 times each . The goal is for the discussion forum to function as robust clinical conferences on the patients. Provide a response to 1 of the 3 discussion prompts that your colleagues provided in their video presentations. You may also provide additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient.
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
Week 4: Case Study SOAP Note
Subjective:
CC (chief complaint): ??I’m here because Wendy told me I need to see the doctor?
HPI: CH is a six-year-old boy with a history of neglect and isolation and parental drug use. He presents with his foster mother for concerns of inattention, hyperactivity, irritability, tantrums, and restless sleep. He’s been living in his current foster home since July 1, 2023. Past history of ADHD combined type, unspecified trauma disorder, oppositional defiant disorder, and autism spectrum disorder. Previous medication trials include guanfacine XR doses of 1-3 milligrams daily. Methylphenidate 2.5 milligrams. CH refrains from physical affection including hugging or touching unless he initiates it. He does not seek comfort for injury but can be consoled when upset. His response is consistent between his foster mother and his relationship with his biological mother who he sees during supervised visits.
He’s easily upset by inconveniences that can become tantrums that last for several minutes. He responds to therapeutic intervention including reflection by taking time in the corner to calm down. Triggers are identifiable. He demonstrates manipulative behavior including bargaining.
He falls asleep easily and sleeps through most of the night. Denies enuresis and infrequent nightmares. Foster mother reports that he is restless in his sleep and will thrash around to the extent that he will fall out of bed. He self-soothes by rocking and humming.
CH engages with the biological children of the foster family although has demonstrated rough play appropriate for his age. He denies aggressive intent and spiteful or vindictive feelings toward others. Foster mother voices concern regarding quote obsession with penis including touching, talking about it, and showing others.
Substance Current Use: CH tested positive for opioids at birth and exhibited signs of neonatal abstinence syndrome with high suspicion of substance exposure in utero. He required NICU and morphine to manage symptoms.
Medical History:
·
Current Medications: Guanfacine ER 2 milligrams QHS, Abilify 2 milligrams QAM
·
Allergies:
NKDA
·
Reproductive Hx:
Puberty not reached. Not sexually active
Social History: CH was removed from his mother’s custody at the age of five months due to neglect. Police were called to the home by neighbors and he was found in the hallway on the floor with needles drugs and paraphernalia around the home. He lived with his maternal grandparents and his eight-year-old brother until March of 2022 when the grandpare
Please respond to this question twice.
· What do you anticipate would be potential challenges that could present in CH??s treatment plan? How can those challenges be mitigated?
· Social support in the role of caregiver is critical to positive outcomes in children. How can the PMHNP best support gaps in social support for CH?
· How can we improve communication and coordination among those involved in CH??s care to ensure that his mental health needs are met?
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