Comprehensive Focused SOAP Psychiatric Evaluation Template.

CC (chief complaint):” my mum said you can help me get better” ( says a 7 years old to the doctor).

HPI: 7 years old male presented to the clinic with his mother for psychiatry evaluation for the complaint of constantly worrying and anxious about his mother and siblings, throwing things at people in school and home and getting in trouble at school and having bad dreams some days and his hesitant to go to school.Per mother, patient thinks his mum is going to leave just like his dad did. Patient also has enuresis that is not responding to DDVP. Patient was referred by his pediatrician.

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Past psychiatric history– Patient has no psychiatry history

Medication trials and current medications– DDVP for enuresis

Psychotherapy or previous psychiatric diagnosis- No history of previous psychotherapy or prior psychiatric hospitalization.

Pertinent substance use- No history of substance abuse

Family psychiatric/substance use. Patient lives with mother, baby brother and their dog (Sparky). His father was in the military. who died in war when he was five. No history of sexual abuse.No known substance abuse in the family. No known family psychiatry history.

Social History- Patient lives with mother with his baby brother.. Patient has a dog called sparky. The patient doesn’t have a good relationship with his baby brother, and thinks he stinks and cries a lot. Patient has no friends in school because he smells from not bathing. He is hyperactive and inattentive in school, constantly getting into trouble and he is isolated from other pupils in school. Patient does not like going to school because he worries about his mother and sibling. Patient is very active with a poor appetite. He has lost about 3 pounds in the last 3 weeks the patient spends time building with his LEGOS and dogs.

Allergies- No known allergies

Medical History: No medical history

· Current Medications: DDVP for enuresis.

· Reproductive Hx: No record on reproductive history.

ROS:

Vitals: BP 117/82, P- 87,T-97.8, R- 16, Spo2-98% in room air

· GENERAL: No fever, chills, weakness, or fatigue. Patient has lost 3 pounds in the last 3 weeks.

· · HEENT: Head is Normocephalic and atraumatic. Claims headache almost everyday, Eye- pupils are equal, no discharges, No double, blurred vision. Ear, Nose, and Throat -No hearing loss, No congestion, no sore throat, and no sneezing

· · SKIN: Skin is warm, No rash or itching

· · CARDIOVASCULAR: No chest pain, No chest pressure, and no edema, No palpitation

· · RESPIRATORY: No respiratory distress.

· · GASTROINTESTINAL: No distension noted. Reported poor appetite and stomach ache

· · GENITOURINARY: Reported enuresis.

· · NEUROLOGICAL: The patient is alert and oriented, no dizziness, numbness, or tingling sensation of the extremities

· · MUSCULOSKELETAL: No muscle pain, No back pain, nobody stiffness, no edema noted

· · HEMATOLOGIC: The patient is not frail and no bleeding.

· LYMPHATICS: No enlarged lymph nodes.

· · ENDOCRINOLOGIC: No reports of polydipsia. Reported sweating and heat intolerance.

Objective:

Diagnostic results: No Diagnostic test stated in the case study. However, Extensive physical examination is very important as well self-assessment questionnaires like Hamilton anxiety scale, Beck anxiety inventory, social phobia anxiety questionnaire can also be used to rule out anxiety. elements of X-rays are not required. However, El Rafei (2017) denotes that if need be, most children with a mental case or assumed to develop one, needs undergo X-ray screenings to ascertain their brain development or unusual changes.

Assessment

Mental Status Examination: He is a 7 year-old male who looks his stated age. He is alert and orientated to time, place, person and situation. Patient was calm and cooperative with the examiner. He is independent of ADL.He is cooperative with the examiner. He is neatly groomed and clean, dressed appropriately.Although, there is a report that a patient urinates at night and refuses to take a bath which makes other people call him smelly in school . There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. the patient expressed needing help with his anxiety. Per mother, Patient is constantly worrying about her and his baby brother. Patient is scared that his mother will leave and not return like his dad. Patient’s dad died in the war when he was 5 years old, which the patient is not aware of and he thinks his father disappeared. Patient is also afraid of the dark.He dreams that he is lost and also hesitates to go to school somedays because he is worried about his mother and siblings. There is no evidence of looseness of association or flight of ideas. There are also reports of inattentiveness, hyperactivity and impulsiveness ( teacher telling him to sit down all the time, throwing books at his classmate, looking out of the window)The hyperactivity in children with mental cases makes them unable to control their impulses (Rajamanickam, 2019).

. Dissatisfaction with sleep quality and quantity which causes because of the night mares. Patient reported that this happens like every other day. He denies any auditory or visual hallucinations.The mother reported loss of appetite and physical symptoms of abdominal pain and weight loss. Patient has lost about 3 pounds in three weeks. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.

There is no evidence of any abnormal motor activity.

Diagnostic Impression

Comprehensive Focused SOAP Psychiatric Evaluation Template.

Reflections:

Case Formulation and Treatment Plan:

References

Bradshaw, T. (2017). Physical health in people with mental health problems. Health Promotion and Wellbeing in People with Mental Health Problems, 12-22. https://doi.org/10.4135/9781529714746.n2

El Rafei, H. (2017). Psychiatric assessment of cases with self-inflicted poisoning in a sample of Egyptian children and adolescents. https://doi.org/10.26226/morressier.5885d718d462b8028d891ff6

Painter, K., & Scannapieco, M. (2021). Framework for understanding and treating mental health problems. Understanding the Mental Health Problems of Children and Adolescents, 14-25. https://doi.org/10.1093/oso/9780190927844.003.0002

Rajamanickam, R. (2019). Mental health legislation for the elderly with mental health problems. https://doi.org/10.15405/epsbs.2019.10.11

Comprehensive Focused SOAP Psychiatric Evaluation Template.