NU580 SOAP Note

NU580 SOAP Note

Student Name

Purdue University Global

NU580 FNP II – Primary Care of Children and Adolescents’ Health

Prof. Name:

Date

NU580 SOAP Note

Amber Renee Carter, a 7-year-old female patient, presents with severe anger, impulsive behaviors, emotional dysregulation, sleep disturbance, and suicidal statements during episodes of intense frustration. Based on the clinical presentation, family history, behavioral changes, and mood symptoms, the most likely diagnosis is bipolar disorder, with autism spectrum disorder (ASD) as a significant comorbid condition requiring continued evaluation and multidisciplinary care.

Patient Information

Patient Name: Amber Renee Carter
Encounter Number: 1
Date of Encounter: 05/09/2024
Age: 7 years
Sex: Female

Chief Complaint

The patient states, “I’m mad. I’m really angry.”

History of Present Illness

Amber presents to the clinic with her stepmother following a referral from Hurley Hospital Emergency Room after an incident where she jumped out of her bedroom window. The patient demonstrates significant anger, impulsivity, and difficulty regulating emotions.

According to her stepmother, Amber has displayed behavioral outbursts for approximately two years, with worsening symptoms since the beginning of the school year. The patient has become increasingly difficult to calm during episodes of anger and has demonstrated impulsive actions that raise safety concerns.

The patient reports fluctuating energy levels and poor sleep patterns. She experiences difficulty falling asleep, wakes multiple times during the night, has difficulty returning to sleep, and frequently wants to get out of bed during nighttime hours. She also reports oversleeping in the morning.

During episodes of severe anger, Amber has made statements expressing thoughts of wanting to die or harm others. Although she has made suicidal statements, she has no history of suicide attempts.

Current Medications

The patient denies taking any medications.

Allergies and Medication Intolerances

• No known allergies.

• Patient denies medication intolerances.

Past Medical History

Amber has a history of autism spectrum disorder (ASD), diagnosed at age two.

She denies:

• Chronic medical illnesses

• Major trauma history

• Previous hospitalizations

• Surgical history

Family History

Amber’s biological mother has a history of an unspecified mental health condition. Due to the presence of mood-related symptoms in the patient and a possible familial psychiatric history, bipolar disorder remains an important diagnostic consideration.

Social History

Amber currently lives with her father and stepmother.

Additional social information includes:

• Patient denies alcohol use.

• Parents report minimal alcohol consumption.

• Family occasionally enjoys a glass of wine after dinner.

Review of Systems

General

Review is significant for behavioral concerns, anger episodes, sleep disturbance, and fluctuating energy levels.

Cardiovascular

Patient denies:

• Chest pain

• Palpitations

• Paroxysmal nocturnal dyspnea

• Orthopnea

• Edema

Respiratory

Patient denies:

• Wheezing

• Hemoptysis

• Shortness of breath

• History of pneumonia

• Tuberculosis exposure

Gastrointestinal

Patient denies:

• Abdominal pain

• Nausea or vomiting

• Diarrhea or constipation

• Hepatitis

• Eating disorders

• Ulcers

• Black or tarry stools

Neurological

Patient denies:

• Syncope

• Seizures

• Weakness

• Paralysis

• Paresthesia

• Blackout episodes

Psychiatric

Patient reports:

• Anger episodes

• Impulsive behaviors

• Sleep difficulties

• Suicidal statements during periods of emotional escalation

The patient denies previous psychiatric diagnoses other than autism spectrum disorder.

Objective Findings

Vital Signs and Measurements

• Weight: 65 lbs

• Height: 3 feet 6 inches

• BMI: Not documented

• Temperature: 36.7°C

• Blood Pressure: 110/76 mmHg

• Pulse: 82 bpm

• Respirations: 18 breaths/minute

Physical Examination

General Appearance

Patient appears well-developed and well-nourished. She is alert and oriented with no apparent physical distress. Ambulation is normal.

Skin

Skin examination reveals:

• Normal coloration

• No lesions or rashes

• No jaundice

• Pink nail beds without cyanosis or clubbing

HEENT

Findings include:

• Normocephalic and atraumatic head

• Pupils equal, round, and reactive to light and accommodation

• Extraocular movements intact

• No conjunctival or scleral abnormalities

• Patent ear canals with normal tympanic membranes

• Pink nasal mucosa with normal turbinates

• Supple neck with full range of motion

• No lymphadenopathy or thyroid abnormalities

• Moist oral mucosa

• No pharyngeal erythema or exudate

Cardiovascular

Cardiac examination demonstrates:

• Regular rate and rhythm

• Normal S1 and S2

• No murmurs, rubs, or extra heart sounds

• Capillary refill of approximately two seconds

• Strong peripheral pulses

• No edema

Respiratory

Respiratory examination is within normal limits with clear breath sounds and normal percussion findings.

Gastrointestinal

Abdominal examination reveals:

• Active bowel sounds in all quadrants

• Soft, non-tender abdomen

• No hepatosplenomegaly

Musculoskeletal

Patient demonstrates:

• Full range of motion in all extremities

• Normal movement throughout examination

• No joint abnormalities

Neurological

Neurological examination reveals:

• Clear speech

• Normal muscle tone

• Stable posture and balance

• Normal gait

• Alert and oriented status

Laboratory Results

The following laboratory studies were within normal limits:

• Basic Metabolic Panel (BMP)

• Complete Blood Count (CBC) with differential

Assessment

Differential Diagnoses

The primary differential diagnoses considered include:

• Autism spectrum disorder (ASD)

• Bipolar disorder

• Childhood-onset schizophrenia

Autism Spectrum Disorder

Autism spectrum disorder is a lifelong neurodevelopmental condition characterized by difficulties with social communication, restricted interests, repetitive behaviors, and challenges with behavioral flexibility.

Amber has a confirmed ASD diagnosis from early childhood, which may contribute to emotional regulation difficulties and behavioral challenges.

Bipolar Disorder

Bipolar disorder is a mood disorder characterized by episodes of mania or hypomania alternating with depressive symptoms. Manic episodes may involve:

• Increased energy

• Reduced need for sleep

• Irritability

• Impulsive decision-making

• Elevated or unstable mood

Amber’s fluctuating energy levels, significant sleep disturbance, impulsivity, severe mood changes, and family psychiatric history support bipolar disorder as the most likely diagnosis.

Childhood Schizophrenia

Childhood schizophrenia is a rare psychiatric disorder involving psychotic symptoms, impaired thinking, emotional disturbances, and functional decline.

Symptoms may include:

• Hallucinations

• Delusions

• Disorganized behavior

• Declining social functioning

Amber’s presentation does not currently demonstrate evidence of psychotic symptoms. However, continued monitoring is appropriate due to the complexity of childhood psychiatric disorders.

Diagnosis

Primary Diagnosis: Bipolar Disorder

Amber’s symptoms are consistent with bipolar disorder due to:

• Severe mood instability

• Increased irritability and anger episodes

• Sleep disruption

• Impulsive behaviors

• Family history suggesting possible genetic vulnerability

Research indicates that genetic risk factors and stressful life experiences may contribute to the development of bipolar disorder symptoms.

Plan and Recommendations

Medications

No medications were initiated during this visit.

Non-Pharmacological Recommendations

The patient and guardian were advised to focus on:

• Maintaining a consistent sleep schedule.

• Ensuring adequate sleep duration, as sleep deprivation may worsen mood instability.

• Encouraging a balanced diet containing:

  • Vegetables and fruits

  • Whole grains

  • Protein-rich foods

• Monitoring changes in mood, energy, behavior, and sleep patterns.

Safety Education

The patient and guardian were advised to seek immediate emergency assistance if Amber:

• Expresses intent to harm herself or others.

• Develops a plan for suicide or violence.

• Demonstrates worsening impulsive or unsafe behaviors.

Screening and Diagnostic Tools

Recommended screening tool:

• Conners Comprehensive Behavior Rating Scale (CBRS)

This assessment may help evaluate behavioral concerns, emotional regulation, attention-related symptoms, and functional impairment.

Education for Parents and Guardians

The guardian was educated regarding:

• Signs and symptoms of bipolar disorder.

• Warning signs of worsening mood episodes.

• Importance of early intervention.

• Need for ongoing psychiatric monitoring.

Referrals

Referral recommended:

• Child and adolescent psychiatry for further evaluation and treatment planning.

Follow-Up

Follow-up as needed (PRN) or sooner if symptoms worsen.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text revision). American Psychiatric Association Publishing.
https://doi.org/10.1176/appi.books.9780890425787

Esposto, E., Nastro, F. F., Lorenzo, G. D., & Ribolsi, M. (2023). Navigating the intersection between autism spectrum disorder and bipolar disorder: A case study. Journal of Psychopathology.
https://www.jpsychopathology.net/

NU580 SOAP Note

Petlovanyi, P., & Tsarkov, A. (2020). Child schizophrenia: Theory and practice. European Journal of Medical and Health Sciences, 2(1).
https://doi.org/10.24018/ejmed.2020.2.1.165