Unit 3 Case Study

Yekaterina Ambrose

Herzing University

Psychiatric Mental Healthcare - 2, NU674-7

Dr. A. Lara Adeyemi

September 24, 2023

 Initial Psychiatric Interview/SOAP Note

Informed consent was given to patient and caregiver about psychiatric interview process. Verbal
and Written consent obtained. Patient and caregiver have the ability/capacity to respond and
appear to understand the risk and benefits of the treatment.

Patient’s name: J.V.

Age:12
Minor:
Accompanied by grandmother.
Demographic: unknown
Gender Identifier note: He/Him
Subjective:
CC: patient’s grandmother reports that patient’s behavior has gotten worse since his sister has
moved in with them.
HPI: patient is accompanied by his grandmother. The patient is currently attending 6 grade in
Middle school. Pt has been recently diagnosed with ODD and ADHD. Pt has been in the care of
his grandmother since the age of 18 months old, after Child protective Service removed him
from his biological parents care due to neglect and physical abuse. Pt’s biological parents had a
history of substance abuse and were not capable of taking appropriate care of Joshua at that time.
Based on CPS reports, patients' biological parents had an unstable and violent relationship, and
pt mother reported having difficulties of taking care of Joshua. At the age of 5, patient had an
attempt to reunite with his parents, which was not successful after patient’s Kindergarten teacher
has noted bruises of patient’s extremities and patient was placed back with his grandmother and
was living with her since then. Patient’s grandmother reports that Joshua’s behavior has gotten
worse since his sister moved in with them recently. Grandmother states that patient feels like he
is not getting enough attention now and his mood shifts from constricted to volatile with frequent
angry outburst that affect the patient’s school performance. Grandmother has also reported that
she has a history of trauma herself, and that Joshua’s recent emotional outburst had made her feel
depressed and overwhelmed. Grandmother reports that she is having difficulties providing
consistent caretaking to both children at this time, including sending them to school.
During assessment: patient reports difficulty sleeping, impaired concentration, edginess and
irritability.
Patient’s self-esteem appears to be fair, no reported feelings of excessive guilt, no reported
anhedonia, does not report change in appetite, does not report libido disturbances, does not report
change in energy.
Patient does not report risk-taking behaviors, pressured speech, or euphoria.
Patient does not report excessive fears, or panic attacks.
Patient does not report hallucinations, delusions, obsessions or compulsions. Patient does not
report symptoms of eating disorders. There is no report of recent weight loss or gain.
SI/HI/AVH: SI/HI/AVH are not reported. There is no report of inappropriate/illegal behavior.
Allergies: not reported.
Past medical HX:
Medical history: there is no report of cardiac, respiratory, endocrine issues or history of head
trauma. Based on CPS’ report (when Joshua was removed from his parent’s house at the age of
18 months), the patient’s biological mother has reported that Joshua was often irritable, restless
and difficult to console. His mother also reported that the patient was “slow to develop”.
There is no report of HX of chronic infections, including MRSA, TB, HIV, Hep C.
Surgical history: not reported.
Past Psychiatric History:
Previous psychiatric diagnoses: patient was recently diagnosed with ODD and ADHD.
Previous medication trials: none reported.
Safety concerns:
History of violence to Self: none reported.
History of violence to others: pt’s grandmother reported that patient becomes easily angered, his
mood shifts from constricted to volatile, with frequent angry outbursts due to pt’s sister moved in
with them recently.
Auditory Hallucinations: none reported.
Visual Hallucinations: none reported.
Mental health treatment history:
History of outpatient treatment: none reported.
History of psychiatric hospitalizations: none reported.
Trauma history: patient was removed from his biological parents care at the age of 18 months
due to neglect, physical abuse and parental substance abuse. Pt’s parents had a violent
relationship. Pt’s grandmother also has HX of childhood trauma.
Substance abuse: there is no report of patient’s Nicotine/Tobacco, ETOH or Substance use.
Current Medications: there is no report of current medications, there is no report of current
supplements.
Family Medical History: there is no report of Family medical history.
Family Psychiatric History:
Substance abuse: pt’s biological parents have HX of ETOH and Substance abuse.
Suicides: none reported.
Psychiatric diagnoses/hospitalizations: pt’s Grandmother has HX of Depression and Childhood
trauma.
Developmental diagnoses: none reported.
Social History:
Occupational History: Pt is currently resides with his grandmother and his sister. Pt is currently a
6th grade student at Middle school. He is taking a following classes at school: Remedial reading,
Math, Science, Art, Social studies and P.E. Pt’s favorite class is Art, and Remedial Reading is his
least favorite. Pt is at least two years behind in reading. Pt does not have IEP plan yet. Pt is
seeing his Mother at family events and holidays; pt did not have contact with his father since the
age of 5.
Military service history: N/A
Developmental History: based on CPS’ report from years ago, pt’s mother has reported that
patient was “slow to develop”.
Legal History: no reported/known legal issues. Pt’s Grandmother is his Legal guardian at this
time.
Spiritual/Cultural Considerations: none reported.
ROS:
Constitutional: no report of fever or weight loss.
Eyes: no report of acute vision changes or eye pain.
ENT: no report of hearing changes or difficulty swallowing.
Cardiac: no report of chest pain, edema or orthopnea.
Respiratory: no report or dyspnea, cough or wheeze.
GI: no report of abdominal pain.
GU: no report of dysuria or hematuria.
Musculoskeletal: no report of joint pain or swelling.
Skin: no report of rush, lesion, abrasion.
Neurological: no report of dizziness, blackout, numbness or focal weakness.
Endocrine: no report of polyuria or polydipsia.
Hematologic: no reports of blood clots or easy bleeding.
Allergy: no reports of hives or allergic reactions.
Reproductive: no report of significant issues.
Objective:
VS: were not obtained.
Labs: were not obtained/none on file.
Physical exam:
MSE:
Appearance: not reported
Mood: labile (shifts from constricted to volatile)
Affect: easily agitated with frequent angry outbursts.
Attention: fair (pt reports impaired concentration).
Judgment: Impaired (pt believes his sister gets more attention than him)
Orientation: not reported.
Speech: unable to assess
Thought content: not reported.
Thought process: not reported.
Assessment:
DSM5 Diagnosis: with ICD-10 codes:
-Oppositional Defiance Disorder, Moderate (ODD). F 91.3
-Attention Deficit Hyperactivity Disorder, Combined type. (ADHD). F 90.2
Differential Diagnoses:
-Posttraumatic Stress Disorder (PTSD). F 43.10
-Adjustment Disorder, with mixed disturbance of emotions and conduct. F43.25
Patient is not responding well to the living arrangements that are currently in place (living with
his grandmother) and is having difficulties adjusting to his sister entering the home. Patient’s
Grandmother, who is pt’s Legal Guardian, appears to understand the need for further treatment.
Pt’s grandmother appears to express the willingness to comply with treatment plan. Reviewed
with patient and his grandmother potential risks and benefits, black box warning, and
alternatives, including declining of treatment.
Plan:
Safety Risk/Plan: patient is found to be unstable to control his emotions/behavior. Patient likely
poses a moderate risk to self and moderate risk to others at this time.
-Pharmacological Interventions:
Start patient on Adderall XR 5 mg, PO, once in the morning after breakfast.
Pharmacological treatment is considered the first line treatment for ADHD. Central nervous
system stimulants are the first choice of medications that have been shown to have the greatest
efficacy with generally mild side effects. Plan: patient will improve his mood by showing
decreased mood lability and angry outburst by at least 50 % by the next appointment in two
weeks. Initial does will be 5mg. If necessary, this dose could be increased by 5mg each week up
to a maximum dose of 40mg per day in divided doses (Stahl, 2021). In general, both Ritalin and
Adderall are both deemed to be effective in treating ADHD (Patel & Morris, 2023).
-Psychotherapy referral for CBT.
-Psychotherapy referral to patient’s grandmother.
-Psychiatrist referral for patient’s grandmother.
Education, including health promotion, maintenance and psychological needs:
-pt was educated about the importance of taking his medication (Adderall) and importance to
continue it despite the improvements of symptoms.
-safety plan was reviewed with the pt and grandmother.
-discussed worsening of symptoms and when to contact the office or report to nearest ED.
-patient was educated about importance of exercise and was encouraged to participate in
extracurricular activities.
-patient/grandmother were educated about importance on proper nutrition and proper hydration.
Excessive sugar consumption as well as some preservatives and food colorings have been shown
to increase ADHD symptoms (Rucklidge et al., 2018). Furthermore, education was provided
explaining that omega-3 supplementation has been shown to improve ADHD symptoms
(Hjalmarsdottir & Arnarson, 2020). Additionally, studies have shown that zinc supplementation
can assist in reducing ADHD symptoms (Hjalmarsdottir & Arnarson, 2020).
-patient was educated about of importance of maintaining a good Sleep Hygiene (keeping
consistent sleep schedule, turning off electronic devices an hour before going to bed, regular
exercise).
-patient/grandmother were educated about most common side effects of Adderall as : stomach
pain, loss of appetite, weight loss, mood change, headache, feeling nervousness, dizziness, dry
mouth.
Follow-up: in two weeks, or earlier as needed.

Visit lasted:55 minutes

Billing Codes for visit: 90832

Yekaterina Ambrose, PMHNP

09/23/23 13:56.
 References
Hjalmarsdottir, F. & Arnarson, A. (2020). Does nutrition play a role in ADHD? Healthline.
https://www.healthline.com/nutrition/nutrition-and-adhd
Patel, A. & Morris, S. (2023). What the difference between Ritalin and Adderall. Healthline.
https://www.healthline.com/health/adhd/adderall-vs-ritalin
Rucklidge, J., Taylor, M. & Johnstone, J. (2018). DO diet and nutrition affect ADHD? Facts and
clinical considerations. Psychiatric Times, 35(9).
https://www.psychiatrictimes.com/view/do-diet-and-nutrition-affect-adhd-facts-and-
clinical-considerations
Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical
application (5th ed.). Cambridge: Cambridge University Press.