Unit 3-Case Study on Joshua- SOAP Note. Due sep 21. 900w and 4 references. Please use course resource textbook and DSM5 as reference. Must Use SOAP Note
Unit 3-Case Study on Joshua- SOAP Note. Due sep 21. 900w and 4 references. Please use course resource textbook and DSM5 as reference. Must Use SOAP Note template attached and case study below.
Read the following case study:
Complete a SOAP Note and treatment plan based on the information provided.
All work should be original and submitted as a Word document unless otherwise indicated in the assignment instructions. ALL assignments need to be APA 7 format and accompanied title page in APA 7th edition format in order that the work would be properly identified for the student, the course, and the assignment. Work submitted without a title page will receive a grade of 0.
Case Vignette—Joshua
Presenting Situation
Joshua is a 12 year old boy who attends Middle School as a 6th grader. Joshua has been in placement with his grandmother for several months. His behavior has been on the decline since his middle sibling was recently placed in the home with him. He was strongly reactive to any signs that his sister was receiving more attention than he was. He becomes easily angered, his moods shift from constricted to volatile, with frequent angry outbursts, that carryover to and interfere with school. Joshua shows multiple signs of arousal (e.g., difficulty sleeping, impaired concentration, edginess and irritability). He was recently diagnosed with oppositional defiant disorder and ADHD although he doesn’t yet have an IEP. In school, he is taking the following classes: Remedial Reading, Math, 6th grade Science, Art, Social Studies and P.E. His favorite class is Art and the Remedial Reading class is his least favorite. He is at least two years behind in reading. When he is in a happy mood, Joshua is talkative and social with his peers.
Joshua’s grandmother, who has her own history of childhood trauma, has become more depressed and overwhelmed by his emotional outbursts and she has had difficulty providing consistent caretaking to either of the children, including sending them to school. She is reluctant to make contact with the school as it just adds one more overwhelming responsibility to her life.
Trauma History
Joshua has been in the care of his Grandmother since he was 18 months old at which time Child Protective Services removed him from his parents’ care due to neglect, physical abuse and parental substance abuse. When initially interviewed by CPS the mother acknowledged that she was under tremendous stress due to an often violent relationship with her husband. She admitted that caring for Joshua was difficult because he was often irritable and rejecting of her attempts to console him. At other times, he was very restless and clingy toward the mother, especially when the father was present. She also said Joshua was “slow to develop.” The mother admitted that she and her husband had a history of drug and alcohol abuse.
At age 5, an attempt to reunify Joshua with his parents failed when he was once again removed from their care due to a report made by his Kindergarten of seeing bruises on Joshua’s legs and arms. He was placed back in care with his grandmother and has been with her since. His parents have separated and he only sees his mother at family events and holidays. He has had no contact with his father since the second set of allegations was substantiated when he was 5
S - (Subjective):
Age: 12
DOB: 05/29/2010
Race: White
Gender: Male
CC: Grandmother reports behaviors are worse than before since his sister moved into the home
HPI:
12-year-old white male recently diagnosed with ODD, and ADHD accompanied by his grandmother, that
reports his moods have been worse since his sister recently moved in with them. Client reports that
since his sister moved in with him and his grandmother that he has had trouble sleeping, concentrating
and feels on edge. According to reports received from his grandmother, he is moody, becomes easily
agitated, has angry outbursts, that interfere with school and becomes easily angered. Joshua’s
grandmother is feeling depressed and overwhelmed, having trouble coping with the responsibility of
caring for Joshua and his sister and having difficulty with following through with sending them to school.
SI/HI: Does not report any thoughts of wanting to hurt himself, but easily agitated and aggressive
towards his sister
Hallucinations: No reported AVHs
Allergies: No food, drug, or environmental allergies
PMH: Recently diagnosed with ODD and ADHD
Past Psychiatric history: No previous inpatient psychiatric stays, currently being followed in outpatient
clinical setting for management of ODD, and ADHD
Safety: Aggression towards others
Trauma: History of physical and emotional abuse while in the care of biological parents
Substance use: Denies using alcohol, tobacco, prescription drugs or illicit street drugs
Current medications: NA
Previous Psych med trials: NA
Family medical history: Unknown
Family Psychiatric history: Grandmother has history of depression and childhood trauma
Family substance abuse history: Mother and Father
Social/Educational history: Full time student, does not engage in sports, enjoys taking his art classes.
Reportedly very social with peers when he is happy, and his moods are stable. No legal issues reported,
mother has minimal involvement, father not in the picture since the age of 5 years old
ROS: Denies fever or cough, no apparent distress noted, skin appears dry and intact
O – (Objective):
Vitals: T 98.4, P 72, R 16, BP 102/68
LABS: CBC, CMP and TSH within normal limits
Exam:
Client appears well nourished, age appropriate, he is alert and oriented to person, place, time and
situation, his affect is appropriate and congruent with mood, he appears calm and relaxed, able to make
and maintain eye contact. Speech is clear and non-pressured, no fidgeting noted. Displays good insight
and judgement, discussed future when finished with school.
A – (Assessment):
DX:
Oppositional Defiance Disorder (ODD) 313.81 (F91.3)
Attention Deficit Hyperactivity Disorder (ADHD) 314.01 (F90.1)
Client is not responding well to interventions currently in place and having trouble adjusting to sibling
entering the home. Grandmother appears to understand the need for further treatment and expressed a willingness to comply with a treatment plan. Reviewed with client and grandmother potential risks &
benefits, black box warnings, and alternatives including declining treatment
P – (Plan):
Current safety contract in place
Client encouraged to participate in extracurricular activities
Grandmother instructed to call the office or walk in if needed prior to next appointment
Client will start Adderall XR 2.5g by mouth daily, and follow up in 2 weeks
Client and Grandmother referred for therapy
Time spent in Psychotherapy 20 minutes
Visit: 55 minutes
Billing Codes for visit: 90832 outpatient visits
Student: Anna Berry, BSN RN, PMHNP-Student
Date: 05/25/2022
Time: 1300-1355