Week 9: Focused Soap Note And Patient Case Presentation

Week 9 Focused SOAP Note and Patient Case Presentation for child/adolescent with Mood Disorder Name College of Nursing-PMHNP, Walden University NRNP/PRAC 6665 PMHNP Care Across the Lifespan I Dr. Date Client Information 12 yr old male with mom Chief ComplaintI am not doing well. History of Illness Disruptive mood dysregulation disorder 296.99 F34.81 Past Psychiatric DMDD. Current Medications Risperidone 2mg AM and 3mg HS Past MedicationsRisperidone 1mg AM and 2mg HS that he stopped taking since end of December. Past Family Psychiatric/MedicalHistoryADHD runs into the family. PsychosocialHistory Born and RaisedMother Marital status childrenN/A Street/Illicit drug useDenies any street drug use. SmokingDenies Alcohol useDenies Legal or Pending ChargeDenies H/O AbuseNo JobN/A Education6th grade Social Security benefits No Family support / other supports in the communityYes Living statusWith family Military H/ON/A Substance Abuse none Medical unremarkable Social Patient states he goes to school. Mother states that he goes to camps in the summer, plays sports, and hangs with friends. Family History He lives with his sister and mother Assessment MSE Orientation alert times 3 currently oriented to person, place, and self. Appearance appropriately dressed Attitude/Behavior Agitated but cooperative, no psychomotor retardation noted. Memory fair Eye Contact fair Speech clear and mostly coherent