Soap Note (Please write about a kid with Mental Illness)
Soap Note (Please write about a kid with Mental Illness)
I need 5 sources not more than 5 years old
D.B.O: 2/24/2019 Age: 3yrs
B.P: 95-110 Temp: 36 pulse: 90 WT: 25 pounds Ht: 34
Gender: F Ethnicity: African Religious affiliation: none Immunization: up-to-date Allergies: none
Chief Complaint (CC): “I am here because I am worried and afraid most of the time, aggressive, and sad.
History of Present Illness (HPI)
The kid’s parent reports that the child appears worried most of the time, anxious, cries a lot, and very aggressive. The three-year-old child face difficulties are sleeping at night due to restlessness. The child has several emotional and behavioral problems worrying, especially constant throwing tantrums, being unhappy, sucking thumb, and having trouble paying attention. Apart from being affected emotionally, the child has trouble sleeping and eating, including physical signs. Due to the emotional and behavioral change, the parents had to remove the child from school, mainly because the kid is not interested and cooperative.
Past Medical History (PMH)
The kid has no past psychiatric medical history.
Drug History (DH)
Family History (FH)
The father has battled anxiety and panic attacks for a long. Psychiatric- therapy and medication have assisted the parent stay calm and fight anxiety.
Social History (SH)
The child was born in Memphis, one of the states that are considered dangerous. The child is raised by a black family, where the father has a lengthy criminal history. According to the neighbors, the father was released from jail recently after being jailed for a controversial murder case. On the other hand, the mother is a victim of drug abuse and still struggling to stay sober. The parents, however, started leaving the kid when she was one year old while going to clubs (Wlodarczyk, et,al.,2017). On the other hand, the parents take alcohol and other drugs in the house while crying for attention (Linares, Azuine, and Singh, 2020). Due to violence, verbal abuse, and neglect, the child has lived with trauma, which has affected her behavior and emotions.
The kid has not yet been taken to school or any daycare. Due to her troublesome nature and aggression, the child has refused to attend school.
Review of Systems (ROS)
General: weight loss in the past two months, trouble falling asleep, weak, and restless.
HEENT: no blurred vision
Cardiovascular: No chest pain
Genitourinary: no incontinence
Neurological: no tremors, no seizures
Allergies: no allergy
Hematological: several bruises on the elbows, ankles, and forehead
Musculoskeletal: no stiffness of joints
Gastrointestinal: no vomiting, nausea, or constipation
Respiratory: no wheezing, coughing, or shortness of breath
Skin: the presence of rashes
Complete Mental Status Examination
General appearance: appears older than three years, dirty clothes, and thin
Behavior: have downcast eye contact, restless, gets agitated
Speech: transparent and fluent
Mood: anxious, worried, and afraid
Motor/gait: normal gait
Judgment: normal judgment
Intellectual functioning: abnormal intelligence for a three-year-old
Attention: restless and lacks concentration
Present three (3) differential and one (1) final diagnosis.
Based on the kid’s medical history, family history, and current mental state, the child may be suffering from opposition defiant disorder, attention-deficit hyperactive disorder (ADHD), or anxiety. There is a higher probability that the child has ADHD, which is primarily genetic, caused by exposure to environmental conditions, mothers’ use of drugs, and alcohol use during pregnancy (Linares, Azuine, and Singh, 2020).
Identify diagnostics, prescriptions, referrals, patient education, and recommended follow-up.
Attention-deficit /hyperactive disorder is the principal diagnosis, which affects a child’s average growth and development. The symptoms provided by the parents and the social, family, and medical history of the child align with those of ADHD (Sayal,et,al.,2018). The mental health transition has no cure, but some treatment that assists manage the condition. The child can be given stimulants, which increase brain chemicals, improving attention and cognition. Also, the child can be taken for therapies, which should be used together with medication since therapy alone cannot effectively treat ADHD (Sanchez,et,al.,2018). Parents should be trained about mental health, the development f positive behaviors in the child, stress management instead of directing their frustration to the child. The parents should also join a support group in the community, which would assist in character development and the development of healthy relationships (Ahmann, Saviet, and Tuttle, 2017).
Cotempla XR-OTD 500gms oral
Quillivant XR 500 gms oral
Adzenys XR-ODT 500 grams oral
Ahmann, E., Saviet, M., & Tuttle, L. J. (2017). Interventions for ADHD in children and teens: A focus on ADHD coaching. Pediatric Nursing, 43(3), 121.
Linares, D. E., Azuine, R. E., & Singh, G. K. (2020). Social Determinants of Health Associated with Mental Health Among US Mothers with Children Aged 0–5 Years. Journal of Women’s Health, 29(8), 1039-1051.
Sanchez, A. L., Cornacchio, D., Poznanski, B., Golik, A. M., Chou, T., & Comer, J. S. (2018). The effectiveness of school-based mental health services for elementary-aged children: A meta-analysis. Journal of the American Academy of Child & Adolescent Psychiatry, 57(3), 153-165.
Sayal, K., Prasad, V., Daley, D., Ford, T., & Coghill, D. (2018). ADHD in children and young people: prevalence, care pathways, and service provision. The Lancet Psychiatry, 5(2), 175-186.
Wlodarczyk, O., Pawils, S., Metzner, F., Kriston, L., Klasen, F., & Ravens-Sieberer, U. (2017). Risk and protective factors for mental health problems in preschool-aged children: cross-sectional results of the BELLA preschool study. Child and Adolescent Psychiatry and Mental Health, 11(1), 1-12.