Unit 3: Clinical SOAP Note for A Pediatric Patient Sample

Unit 3: Clinical SOAP Note for A Pediatric Patient. The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. 

Patient Particulars Initials: L.A.G     Age: 7 Years    Gender: Girl       Race/Ethnicity: Hispanic White of Cuban Origin


CC (chief complaint): ‘She displays unusual behavior ad is constantly on the move


The eleven-year-old girl presents to the clinic accompanied by her guardian, the chief informant in this case. The guardian who doubles as the girl’s maternal auntie reports that her niece continually exhibits unusual behavior that predominantly includes moving around. She further states that the girl does not seem to concentrate on any task and admits having received reports from the child’s elementary class teacher, who complains that the girl is too disruptive to complete any task assigned to her by the teachers. The girl is a seven-year-old female of Hispanic White of Cuban origin whose clinical manifestations are marked hyperactivity, inattentiveness, and impulsivity whose onset was nine weeks ago and appear to be increasing in intensity. The Guardian, however, notes that these symptoms are not accompanied by a lack of understanding given instructions on the child’s part while simultaneously stating that in her considered opinion, the child is not defiant as such. According to the Guardian, the girl’s symptoms may exacerbate at any time of the day, but a little scolding appears to relieve the symptoms only for a short while. The guardian, a community health worker by occupation, rates the symptoms severity 7/10 of ADHD T-Score on a scale of 1-10.

Substance Current Use: N/A                                        

Medical History:

  • Current Medications: Presently not on medication either prescription or OTC.
  • Allergies:  Guardian reports girl is allergic to penicillin. No other known allergies to foods, environmental factors or even other medication.
  • Reproductive Hx: No gynecological issues, or STIs.


  • GENERAL: Patient denies feeling warm/hot. Guardian reports no unusual weight loss or gain in the girl. She however reports the girl is hyperactive, impulsive and inattentive and adds that these three are not associated with lack of comprehension on the girl.  She sleeps adequately for a girl her age 8-10 hours daily.
  • HEENT: No head injuries, scars swellings. Negative for eye pain, itching, or dryness. No eye discharge or redness. Denies photophobia. Denies hearing difficulties, negative for ear discharge, and no sneezes. The child has no runny nose and no sore throat.
  • SKIN: Normal skin turgor, no dryness, unusual coloration.
  • CARDIOVASCULAR: Negative for chest pains or discomfort, no palpitations.
  • RESPIRATORY:  No shortness of breath, no coughs or phlegm
  • GASTROINTESTINAL: Guardian reports the child has no nausea, no vomiting or lack of appetite. Admits normal bowel movements in the child.
  • GENITOURINARY: Patient denies any polyuria, or experiencing a burning sensation when passing urine.
  • NEUROLOGICAL: Denies headache, unstable walking, numbness or unusual bowel movements and emptying.
  • MUSCULOSKELETAL: Negative joint pains, no muscle pain and no muscle or joint stiffness.
  • HEMATOLOGIC: Both girl and guardian deny unusual bleeding or fatigue.
  • LYMPHATICS: No glandular swellings.
  • ENDOCRINOLOGIC:  Both girl and guardian deny excessive urination, or excessive water intake in the girl. They also report no heat intolerance or excessive sweating.


General: The girl is well-groomed, dressed for occasion, well-nourished, and appears the stated age.

Vital signs: Heart rate: 91; Respiratory rate: 19; Temperature: 99.3°F; Blood pressure: 111/71; Height: 52 inches; Weight: 57 lb; BMI: 15.1 (BMI-for-age at the 33rd percentile). The girl’s weight is within the recommended healthy weight range (Cheng, 2020)

HEENT: Head norm cephalic with no trauma or abnormal contours. Both pupils’ equal, round, and reactive to light and accommodation (PERRLA). Extraocular muscles are intact. On palpation nasal sinus passages are non-tender. Tympanic membrane is intact with no discharge or erythema. Negative for both halitosis and exudates in throat.

Neurologic:  Positive for normal symmetric reflexes and intact cranial nerves. Alert and oriented in time, space, person, and place. Negative for deficits in motor, sensory, focal deficit sites.

Psychiatric: Mood congruent with content. Responses are rushed but appropriate to the context given. Appropriately groomed. Constantly fidgets and remains restless throughout the assessment. Unable to maintain eye contact and concentrate for long.

Diagnostic results:

(1) DSM-5 criteria for ADHD. The girl meets criteria 1 and 2 for inattention together with hyperactivity and impulsivity (El Saied & EissarSaad, 2019).

 (2) Blood lead metal levels to rule out lead poisoning which causes similar symptoms (Donzelli et al., 2019)

(3) Swanson, Nolan, and Pelham version IV scale teacher form or SNAP-IV to confirm ADHD (Moraes et al., 2020).

(4) CBC to rule out systemic infections (Leach, 2014)

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Mental Status Examination:

Appearance: 7 yo Hispanic white girl, appears her stated age and appropriately attired/ groomed for the clinic’s visit.

Behavior: Not in distress but has challenges concentrating during the interview. Laughs and smiles inappropriately.

Motor activity Hyperactive with optimal psychomotor agitation present. Normal posture no EPS, tremors or tics.

Speech Speaks at fast rate considering the average level of a 7–8-year-old learners speaks between 89 and 149 while she speaks over 155 per minute. She also blurts out answers cannot wait for her turn to speak at times. Fluent, pressured rate, with a regular rhythm, volume, and a jovial tone.

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Mood fanciful

Affect Elated congruent but sometimes inappropriate

Thought processManifests flight of ideas sometimes.

Though content Negative for suicidal / homicidal ideations

Perceptions Positive for increased perceptual functions with heightened sense of smell

Cognition alert and oriented to person, place, and time. Attention/ concentration poor as she could spell the word SKIRT backward though she could forward.

Memory could recall 5/5 objects immediately and after 2 minutes long term memory intact she could recall the name of child care cent she attended.

Abstract Reasoning Intact identified a cup and car as two non-living things.

Insight moderately poor for a girl her age

Judgement poor

Diagnostic Impression/ Differential diagnosis

  1. F90.2 ADHD combined type (Confirmed) 

Psychiatric and mental health care providers are advised to initiate ADHD evaluation for children between 4 and 18. I confirmed the diagnosis for ADHD combined type because the child exhibited six or more inattention, hyperactivity, and impulsivity (Cabral et al., 2020). For inattentiveness, the girl could not give close attention to details, made careless mistakes at school, and had trouble holding attention to tasks or play activities. She also avoided or expressed dislike for activities that require mental effort. The parent also noted that the girl had challenges organizing tasks and losing things. Similarly, hyperactivity and impulsivity were present as she constantly fidgets, leaves the seat in contexts where remaining seated would be expected, and talks excessively. She has difficulties waiting for her turn and interrupted the guidance many times. The diagnostic results for Swanson, Nolan, and Pelham version IV scale teacher form or SNAP-IV to confirm ADHD and DSM-5 ADHD tests were positive hence the provider confirmed. Using the ADHD mnemonic, the child displayed six or more of the parameters for inattentiveness – when the child is inattentive, you CALL FOR FRED and that when she is hyperactive-impulsive, she tends to RUN FASTT- (Kadiyala, 2019).After assessing the girl for potential coexisting conditions, blood lead metal levels with symptoms of ADHD and CBC that returned negative results helped rule out systemic infections.

  • Oppositional Defiant Disorder Refuted

Like ADHD, ODD manifests with a pattern of disruptive behavior. However, in this patient’s case, the symptoms that dominated are she gets easily distracted, generally disorganized, and could not sit still for a long time. However, in children with ODD, the defining symptoms are getting angry, remaining defiant, and vindictive. The absence of the latter symptoms helped rule out ODD (Aggarwal & Marwaha, 2020).

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  • Autism Spectrum Disorder Refuted

It is essential to acknowledge that both ADHD and ASD are distinct neurodevelopmental disorders with some common symptoms but distinguishing features. A patient can have two conditions at the same time. In this girl patient case, she appears to have difficulties paying attention and not the limited scope of interest characteristic of ASD. The ASD child seems obsessed with a thing or two that they enjoy. ASD onset of symptoms is usually before three years, while ADH is generally after four years. The ASD child has difficulty expressing their thoughts and emotions in communication, whereas the ADHD sufferer talks excessively, interrupt others, and wants to have the last word. Therefore, the absence of characteristics associated with ASD helped rule it out as a likely diagnosis.


Case Formulation and Treatment Plan

PMHNPS should formulate a treatment program designed to address a chronic condition. Subsequently, the provider to adopt a multimodal approach that integrates parental, school, and behavioral interventions. The provider must customize the treatment plan to suit the patient, with the therapist collaborating with the parent and child and school staff to help specify the target outcomes while also guiding ADHD management. Behavioral interventions are the first line of treatment in this case. These include creating a schedule and helping the child organize everyday items. Other behavioral techniques should include positive reinforcement, time out, response cost, and token economy. With time peer tutoring, preferably of gender the same, the patient would help. The other family members should also attend group therapy and family or caregiver education to learn how best to help the ADHD pediatric patient. At school, the teachers can use modified homework assignments, testing methods, and variable deadlines besides using valuable tools like a tape recorder, calculator, and many others. In addition to non-pharmacological interventions, stimulants like Methylphenidate (Ching et al., 2019). These scholars opine that FDA recommends 60mg/d for immediate release and 54mg/d for extended release as methylphenidate maximum dose in pediatric patients between 6 and 12 years.

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Follow-up visits should place in the treatment plan to ensure periodic monitoring of the effects of each treatment adopted. The initial follow-up is slated to happen after one month, followed by another two times within the next coming nine months. After establishing the treatment regimen, other follow-up visits should occur every two times a year.


Referral to a behavioral healthcare provider will take precedence to conduct further assessment and consider different treatments should the pediatric patient fail two stimulant medication trials.


Aggarwal, A., & Marwaha, R. (2020). Oppositional Defiant Disorder. StatPearls [Internet].

Cabral, M. D. I., Liu, S., & Soares, N. (2020). Attention-deficit/hyperactivity disorder: diagnostic criteria, epidemiology, risk factors and evaluation in youth. Translational pediatrics9(Suppl 1), S104.

Cheng, H., Eames-Brown, R., Tutt, A., Laws, R., Blight, V., McKenzie, A., … & Denney-Wilson, E. (2020). Promoting healthy weight for all young children: a mixed methods study of child and family health nurses’ perceptions of barriers and how to overcome them. BMC nursing19(1), 1-14.

Ching, C., Eslick, G. D., & Poulton, A. S. (2019). Evaluation of methylphenidate safety and maximum-dose titration rationale in attention-deficit/hyperactivity disorder: a meta-analysis. JAMA pediatrics173(7), 630-639.

Donzelli, G., Carducci, A., Llopis-Gonzalez, A., Verani, M., Llopis-Morales, A., Cioni, L., & Morales-Suárez-Varela, M. (2019). The association between lead and attention-deficit/hyperactivity disorder: a systematic review. International journal of environmental research and public health16(3), 382.

El Saied El Banna, A., & Eissa Saad, M. A. (2019). Attention-Deficit/Hyperactivity Disorder: Insights from DSM-5. International Journal of Psycho-Educational Sciences8, 25-29.

Kadiyala, P. K. (2020). Mnemonics for diagnostic criteria of DSM V mental disorders: a scoping review. General psychiatry33(3).

Leach, M. (2014). Interpretation of the full blood count in systemic disease-a guide for the physician. Author reply. The journal of the Royal College of Physicians of Edinburgh44(2), 189-189.

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All the Best, 

Cathy, CS