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Case Study SOAP Note
Nicole Sears
Herzing
University
NU674- Psychiatric Mental Healthcare II
Dr. A. Lara Adeyemi, DNP., PMHNP-BC., AGPCNP-C.
January 28, 2024
, 2
SUBJECTIVE DATA: Joshua 12 year old minor male patient, he/him pronouns
Chief Complaint: “Behavior has been on the decline since his middle sibling was recently
placed in the home with him”
HPI: Patient is a 12 year old male with a history of Oppositional Defiant Disorder and ADHD.
Per report patient’s behavior has been declining since his middle schooler sister has moved into
the home where he lives with his grandmother, and has lived for most of his life. He responds
negatively to any indicators that the sister might be receiving more attention than he is. He gets
easily upset, with labile moods shifting from constricted to volatile. He frequently has angry
outbursts that leave the home and carryover into his school, interfering with his education and
completion of work. He reports poor sleep, decreased concentration, edginess, and irritability. He
is not doing well in school and is especially behind in reading by two years. His grandmother has
her own mental health issues which is being exacerbated by Joshua’s emotional outbursts. It is
leading to her being an inconsistent caretaker for the children, and often means that the children
are not attending school regularly. Joshua’s grandmother is hesitant to get anyone involved from
the school department because it seems overwhelming to her. Per the report at times Joshua can
be seen in a happy mood and social and interactive with peers. There are no reports of patient
having suicidal ideation or self-injurious behavior. No reports of AH/VH/HI
Past Medical History: Pt has a recent diagnosis of Oppositional Defiant Disorder and ADHD,
it has not been reported if he is currently taking medication for same. There is no record if
patient has ever exhibited these behaviors before or approximately how long they have been
happening. Per report mother says that as an infant Joshua was “often irritable and rejecting of
her attempts to console him. At other times, he was very restless and clingy toward the mother”.
Mother also states that Joshua was “slow to develop” as a child and admits to drug and alcohol
abuse.
Unknown if this occurred while pregnant. No other medical history has been reported.
Allergies: none reported
Medications: None reported
Social History: Patient currently lives with grandmother, who he has lived with for most of his
life. Also residing in the residence is his sister who is in middle school. Per report patient has a
significant trauma history that resulted in him being removed from the custody of his biological
mother and father at 18 months old by Child Protective Services and given to his grandmother
due to neglect, physical abuse and parental substance abuse. At that time mother admitted to
feeling tremendous stress surrounding the daily needs of taking care of Joshua and an often
violent relationship with her husband.
Family History: Patients mother and father have a history of drug and alcohol abuse
ROS:
Constitutional: not reported
Head: not reported
Eyes: not reported
Case Study SOAP Note
Nicole Sears
Herzing
University
NU674- Psychiatric Mental Healthcare II
Dr. A. Lara Adeyemi, DNP., PMHNP-BC., AGPCNP-C.
January 28, 2024
, 2
SUBJECTIVE DATA: Joshua 12 year old minor male patient, he/him pronouns
Chief Complaint: “Behavior has been on the decline since his middle sibling was recently
placed in the home with him”
HPI: Patient is a 12 year old male with a history of Oppositional Defiant Disorder and ADHD.
Per report patient’s behavior has been declining since his middle schooler sister has moved into
the home where he lives with his grandmother, and has lived for most of his life. He responds
negatively to any indicators that the sister might be receiving more attention than he is. He gets
easily upset, with labile moods shifting from constricted to volatile. He frequently has angry
outbursts that leave the home and carryover into his school, interfering with his education and
completion of work. He reports poor sleep, decreased concentration, edginess, and irritability. He
is not doing well in school and is especially behind in reading by two years. His grandmother has
her own mental health issues which is being exacerbated by Joshua’s emotional outbursts. It is
leading to her being an inconsistent caretaker for the children, and often means that the children
are not attending school regularly. Joshua’s grandmother is hesitant to get anyone involved from
the school department because it seems overwhelming to her. Per the report at times Joshua can
be seen in a happy mood and social and interactive with peers. There are no reports of patient
having suicidal ideation or self-injurious behavior. No reports of AH/VH/HI
Past Medical History: Pt has a recent diagnosis of Oppositional Defiant Disorder and ADHD,
it has not been reported if he is currently taking medication for same. There is no record if
patient has ever exhibited these behaviors before or approximately how long they have been
happening. Per report mother says that as an infant Joshua was “often irritable and rejecting of
her attempts to console him. At other times, he was very restless and clingy toward the mother”.
Mother also states that Joshua was “slow to develop” as a child and admits to drug and alcohol
abuse.
Unknown if this occurred while pregnant. No other medical history has been reported.
Allergies: none reported
Medications: None reported
Social History: Patient currently lives with grandmother, who he has lived with for most of his
life. Also residing in the residence is his sister who is in middle school. Per report patient has a
significant trauma history that resulted in him being removed from the custody of his biological
mother and father at 18 months old by Child Protective Services and given to his grandmother
due to neglect, physical abuse and parental substance abuse. At that time mother admitted to
feeling tremendous stress surrounding the daily needs of taking care of Joshua and an often
violent relationship with her husband.
Family History: Patients mother and father have a history of drug and alcohol abuse
ROS:
Constitutional: not reported
Head: not reported
Eyes: not reported
