Here are five complete SOAP psychiatric evaluations built on the Walden NRNP/PRAC 6665 & 6675 template, each with full S-O-A-P sections (CC, HPI, substance use, medical/reproductive history, meds, allergies, ROS, diagnostic results, physical exam, MSE, three differential diagnoses with DSM-5-TR justification, reflections, and plan).
The five cases cover: Major Depressive Disorder, Generalized Anxiety Disorder, PTSD, Bipolar I Disorder (manic episode), and ADHD (combined presentation).
Comprehensive Focused SOAP
Psychiatric Evaluation
Five Worked Examples
NRNP/PRAC 6665 & 6675: PMHNP Care Across the Lifespan
Walden University
College of Nursing
Student Name: ____________________
Date: ____________________
EXAMPLE 1
Comprehensive Focused SOAP Psychiatric Evaluation Template
CC (chief complaint): “I just don’t see the point in anything anymore.”
Subjective:
CC (chief complaint): “I just don’t see the point in anything anymore.”
HPI: Ms. J.M. is a 32-year-old married African American female who presents for psychiatric evaluation reporting an 8-week history of progressively worsening depressed mood. She describes persistent sadness present nearly every day for most of the day, accompanied by markedly diminished interest in activities she previously enjoyed, including reading and spending time with friends. She endorses initial and middle insomnia, sleeping only 3–4 hours per night, with early morning awakening around 4:00 a.m. She reports decreased appetite with an unintentional 12-pound weight loss over the past two months. She describes profound fatigue, difficulty concentrating at work, and feelings of worthlessness and excessive guilt about being “a burden” to her husband. She endorses passive suicidal ideation (“I sometimes wish I wouldn’t wake up”) but denies active intent, plan, or access to means. Symptoms began following a miscarriage approximately 10 weeks ago. She denies current alcohol or substance use and denies any prior psychiatric treatment.
Substance Current Use: Denies tobacco use. Drinks 1–2 glasses of wine socially, last use 3 weeks ago. Denies illicit drug use. No history of withdrawal or treatment.
Medical History: No chronic medical conditions. Recent obstetric loss (miscarriage) at 8 weeks gestation, 10 weeks ago. Last physical exam 6 months ago was unremarkable.
Current Medications: Multivitamin daily. No psychotropic medications. No known drug allergies.
Allergies: NKDA.
Reproductive Hx: G2P1, one living child age 4; recent miscarriage. LMP 2 weeks ago. Currently using oral contraceptives.
ROS:
GENERAL: Reports fatigue and 12-lb weight loss. Denies fever or chills.
HEENT: Denies headache, visual changes, or sore throat.
CARDIOVASCULAR: Denies chest pain or palpitations.
RESPIRATORY: Denies shortness of breath or cough.
GI: Reports decreased appetite. Denies nausea or abdominal pain.
NEUROLOGICAL: Reports poor concentration. Denies dizziness or numbness.
PSYCHIATRIC: Reports depressed mood, anhedonia, insomnia, guilt, and passive suicidal ideation.
Objective:
Diagnostic results: PHQ-9 score 19 (moderately severe depression). TSH, CBC, and CMP ordered to rule out organic contributors (thyroid dysfunction, anemia). No imaging indicated at this time.
Physical exam (if applicable): Vital signs: BP 118/74, HR 78, RR 16, Temp 98.4°F, BMI 21.3. General: alert, cooperative, appears stated age, mildly disheveled, tearful at times. Physical exam deferred to primary care; no acute distress noted.
Assessment:
Mental Status Examination:
The patient is a 32-year-old female who appears her stated age, dressed casually with mildly diminished grooming. She is calm and cooperative with appropriate eye contact. Psychomotor activity is mildly retarded. Speech is soft in volume, decreased in rate, with normal articulation. Mood is reported as “empty and sad.” Affect is constricted and congruent with mood, tearful. Thought process is linear and goal-directed. Thought content reveals passive suicidal ideation without active intent, plan, or means; no homicidal ideation; no delusions. No perceptual disturbances, hallucinations, or illusions reported or observed. She is alert and oriented to person, place, time, and situation. Attention and concentration are mildly impaired. Recent and remote memory are intact. Insight is fair; judgment is intact. Estimated intellectual functioning is average.
Diagnostic Impression:
1. Major Depressive Disorder, single episode, moderate (F32.1) — The patient meets DSM-5-TR criteria with five or more symptoms present during the same two-week period, including depressed mood and anhedonia, plus insomnia, significant weight loss, fatigue, feelings of worthlessness, impaired concentration, and recurrent thoughts of death. Symptoms cause clinically significant distress and functional impairment and are not attributable to a substance or medical condition. This is the primary diagnosis.
2. Adjustment Disorder with Depressed Mood (F43.21) — Considered given the temporal relationship to the recent miscarriage; however, the number, severity, and duration of symptoms exceed the threshold for adjustment disorder, making MDD the more accurate diagnosis.
3. Persistent Depressive Disorder (Dysthymia) (F34.1) — Considered but excluded because symptoms have been present for only 8 weeks rather than the required two-year duration.
Reflections:
This case reinforced the importance of distinguishing a major depressive episode from a normative grief reaction following pregnancy loss. The DSM-5-TR removal of the bereavement exclusion allows clinicians to diagnose MDD even in the context of significant loss when full criteria are met. If I were to conduct this evaluation again, I would more thoroughly explore the patient’s social support and perinatal history. An ethical consideration central to this case is the management of passive suicidal ideation: safety planning, lethal means counseling, and clear documentation are essential. A social determinant of health relevant here is access to perinatal mental health resources, which are often underutilized among women of color. Health promotion would include education on sleep hygiene, behavioral activation, and the importance of follow-up.
Plan:
Initiate sertraline 50 mg PO daily, an SSRI with strong evidence and a favorable safety profile in women of reproductive age. Begin weekly cognitive behavioral therapy with a focus on grief processing and behavioral activation. Conduct collaborative safety planning and lethal means counseling; provide the 988 Suicide & Crisis Lifeline. Order TSH, CBC, and CMP. Patient education on medication onset (2–6 weeks), potential side effects, and the importance of not discontinuing abruptly. Follow up in 2 weeks to assess response, tolerability, and suicidality. Return precautions reviewed.
EXAMPLE 2
Comprehensive Focused SOAP Psychiatric Evaluation Template
CC (chief complaint): “I can’t stop worrying about everything, and it’s wearing me out.”
Subjective:
CC (chief complaint): “I can’t stop worrying about everything, and it’s wearing me out.”
HPI: Mr. R.T. is a 45-year-old divorced Caucasian male presenting with a chief complaint of excessive, uncontrollable worry persisting for the past 10 months. He reports worrying “about everything” — finances, his job performance, his teenage children’s safety, and his health — on more days than not. He describes the worry as difficult to control and out of proportion to actual circumstances. Associated symptoms include restlessness, feeling “on edge,” difficulty concentrating, irritability, muscle tension (particularly in the neck and shoulders), and difficulty falling asleep. He reports the symptoms have impaired his work, with colleagues noting he seems distracted, and have contributed to declining relationships with his children. He denies discrete panic attacks but acknowledges occasional episodes of his “heart racing.” He denies depressed mood as the predominant complaint, though he notes feeling “worn down.” He has tried over-the-counter sleep aids without relief. No prior psychiatric history.
Substance Current Use: Drinks 3–4 cups of coffee daily. Reports increasing alcohol use to “wind down,” now 2–3 beers most evenings. Denies tobacco or illicit drugs. No prior substance treatment.
Medical History: Hypertension, diagnosed 3 years ago, well controlled. Gastroesophageal reflux disease. No history of thyroid disease. Last physical exam 4 months ago.
Current Medications: Lisinopril 10 mg daily; omeprazole 20 mg daily; occasional OTC diphenhydramine for sleep.
Allergies: Penicillin (rash).
Reproductive Hx: Not applicable; reports normal sexual function, no concerns.
ROS:
GENERAL: Reports fatigue and feeling worn down. Denies fever or weight change.
HEENT: Denies vision changes. Reports occasional tension headaches.
CARDIOVASCULAR: Reports occasional palpitations. Denies chest pain or edema.
RESPIRATORY: Denies shortness of breath or wheezing.
MUSCULOSKELETAL: Reports chronic neck and shoulder muscle tension.
NEUROLOGICAL: Reports difficulty concentrating. Denies tremor or seizures.
PSYCHIATRIC: Reports excessive worry, restlessness, irritability, and initial insomnia.
Objective:
Diagnostic results: GAD-7 score 16 (severe anxiety). TSH ordered to rule out hyperthyroidism. Consider ECG given palpitations and stimulant (caffeine/alcohol) use. No imaging indicated.
Physical exam (if applicable): Vital signs: BP 132/84, HR 88, RR 18, Temp 98.6°F, BMI 27.1. General: alert, cooperative, appears mildly tense, frequently shifting in seat. No acute distress. Physical exam otherwise deferred to primary care.
Assessment:
Mental Status Examination:
The patient is a 45-year-old male who appears his stated age, appropriately and neatly groomed. He is cooperative with good eye contact but appears restless, frequently shifting in his chair and wringing his hands. Psychomotor activity is mildly increased. Speech is normal in rate and volume with occasional rapid bursts. Mood is described as “anxious and tired.” Affect is anxious, mildly constricted, congruent with mood. Thought process is logical and goal-directed, though tangential when discussing worries. Thought content reveals excessive worry across multiple domains; no suicidal or homicidal ideation; no delusions. No perceptual disturbances. Alert and oriented x4. Attention is mildly impaired; concentration reduced. Memory intact. Insight is good; judgment is intact. Cognition grossly intact.
Diagnostic Impression:
1. Generalized Anxiety Disorder (F41.1) — The patient meets DSM-5-TR criteria: excessive anxiety and worry occurring more days than not for at least six months, about multiple events; difficulty controlling the worry; and three or more associated symptoms (restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance). The disturbance causes significant impairment and is not better explained by another condition. This is the primary diagnosis.
2. Alcohol Use Disorder, mild (F10.10) — Considered given escalating use of alcohol to manage symptoms; warrants further assessment. Substance use may also be exacerbating anxiety and must be addressed concurrently.
3. Caffeine-Induced Anxiety Disorder (F15.980) — Considered given high caffeine intake; excessive caffeine can produce or worsen anxiety symptoms, requiring reduction before final attribution.
Reflections:
This case highlighted the bidirectional relationship between substance use and anxiety. The patient’s escalating alcohol and high caffeine intake likely both contribute to and result from his anxiety, complicating the diagnostic picture. If repeating this evaluation, I would dedicate more time to a detailed substance use timeline and motivational interviewing. An ethical and legal consideration is the duty to address potential alcohol misuse compassionately without stigmatizing the patient. A relevant social determinant is occupational stress and the chronic strain teachers face, which can perpetuate anxiety. Health promotion includes caffeine and alcohol reduction, sleep hygiene, and relaxation techniques such as diaphragmatic breathing.
Plan:
Initiate escitalopram 10 mg PO daily, a first-line SSRI for GAD. Avoid benzodiazepines given alcohol use risk. Refer for cognitive behavioral therapy with relaxation training and worry-exposure techniques. Counsel on reducing caffeine to one cup daily and on alcohol reduction; provide brief intervention and screen further at follow-up. Order TSH and ECG. Educate on medication onset and side effects. Provide crisis resources. Follow up in 3 weeks to evaluate response, tolerability, and substance use.
EXAMPLE 3
Comprehensive Focused SOAP Psychiatric Evaluation Template
CC (chief complaint): “I can’t stop reliving what happened, and I feel like I’m always in danger.”
Subjective:
CC (chief complaint): “I can’t stop reliving what happened, and I feel like I’m always in danger.”
HPI: Mr. L.G. is a 29-year-old single Hispanic male and U.S. Army veteran presenting with symptoms following a combat deployment that ended 14 months ago. He reports recurrent, intrusive distressing memories of an improvised explosive device explosion in which two members of his unit were killed. He experiences nightmares 4–5 nights per week and reports dissociative flashbacks triggered by loud noises and crowds. He actively avoids news coverage of war, fireworks, and large gatherings. He endorses persistent negative beliefs (“I should have done something”), survivor guilt, emotional numbing, and detachment from family and friends. He reports hypervigilance, an exaggerated startle response, irritability with occasional verbal outbursts, difficulty concentrating, and significant sleep disturbance. Symptoms have persisted for more than a year and have caused him to withdraw socially and struggle at work. He denies suicidal intent but admits to fleeting thoughts that “everyone would be better off.” He denies prior psychiatric treatment due to stigma concerns.
Substance Current Use: Reports binge drinking on weekends (6–8 drinks) to “numb out” and help sleep. Smokes half a pack of cigarettes daily. Denies illicit drugs. No prior treatment.
Medical History: Mild traumatic brain injury during deployment (blast exposure), no current sequelae per prior evaluation. Chronic low back pain. Last physical exam 8 months ago at VA.
Current Medications: Ibuprofen 600 mg PRN for back pain. No psychotropic medications. NKDA.
Allergies: NKDA.
Reproductive Hx: Not applicable; declined to discuss in detail.
ROS:
GENERAL: Reports poor sleep and fatigue. Denies fever or weight change.
HEENT: Reports occasional headaches. Denies vision or hearing changes.
CARDIOVASCULAR: Reports palpitations during flashbacks. Denies chest pain.
RESPIRATORY: Denies shortness of breath or cough.
MUSCULOSKELETAL: Reports chronic low back pain.
NEUROLOGICAL: Reports poor concentration and hyperstartle. Denies seizures.
PSYCHIATRIC: Reports intrusive memories, nightmares, flashbacks, avoidance, hypervigilance, and irritability.
Objective:
Diagnostic results: PCL-5 (PTSD Checklist for DSM-5) score 52, exceeding the provisional diagnostic threshold of 31–33. AUDIT screen positive for hazardous drinking. CBC and CMP ordered. No imaging indicated unless TBI sequelae suspected.
Physical exam (if applicable): Vital signs: BP 128/80, HR 92, RR 18, Temp 98.7°F, BMI 25.6. General: alert, guarded, hypervigilant, scanning the room, startles at hallway noise. No acute distress. Physical exam deferred to VA primary care.
Assessment:
Mental Status Examination:
The patient is a 29-year-old male appearing his stated age, casually dressed and adequately groomed. He is guarded but cooperative, with intermittent eye contact and visible hypervigilance, scanning the environment. Psychomotor activity is increased with a startle response to external noise. Speech is normal in rate and volume but terse. Mood is described as “on guard.” Affect is anxious and restricted with episodes of tearfulness when describing the trauma. Thought process is logical and goal-directed. Thought content reveals trauma-related preoccupations, survivor guilt, and passive death wishes without intent or plan; no homicidal ideation; no delusions. No frank hallucinations, though he reports trauma-related flashbacks. Alert and oriented x4. Attention and concentration impaired. Memory intact. Insight is fair; judgment is intact. Cognition grossly intact.
Diagnostic Impression:
1. Posttraumatic Stress Disorder (F43.10) — The patient meets DSM-5-TR criteria: exposure to actual death/serious injury (Criterion A); intrusion symptoms including memories, nightmares, and flashbacks (Criterion B); persistent avoidance (Criterion C); negative alterations in cognition and mood, including survivor guilt and detachment (Criterion D); and marked alterations in arousal and reactivity, including hypervigilance, irritability, and exaggerated startle (Criterion E). Duration exceeds one month with significant functional impairment. This is the primary diagnosis.
2. Alcohol Use Disorder, moderate (F10.20) — Considered given the pattern of binge drinking used as self-medication; comorbid with PTSD in a substantial proportion of veterans and requires integrated treatment.
3. Major Depressive Disorder (F32.x) — Considered given anhedonia, guilt, and passive death wishes; however, symptoms are better accounted for by PTSD’s negative cognition cluster at this time, warranting monitoring.
Reflections:
This case underscored the high comorbidity of PTSD and substance use disorders among veterans and the powerful role of stigma in delaying care. If I were to repeat the evaluation, I would incorporate a more structured trauma-informed approach and explicitly normalize help-seeking. Ethical considerations include respecting the patient’s autonomy and pacing trauma disclosure to avoid re-traumatization. A critical social determinant of health is access to and trust in the VA system, alongside cultural factors affecting how Hispanic male veterans express distress. Health promotion includes connecting the patient to peer support, trauma-focused therapy, and harm-reduction strategies for alcohol use.
Plan:
Initiate sertraline 50 mg PO daily, FDA-approved for PTSD, with planned titration. Refer for trauma-focused psychotherapy (Prolonged Exposure or Cognitive Processing Therapy). Consider prazosin for trauma-related nightmares after baseline blood pressure monitoring. Provide brief alcohol intervention and refer to integrated PTSD/SUD program. Coordinate care with the VA. Conduct safety planning given passive death wishes; provide Veterans Crisis Line (988, then press 1). Educate on PTSD as a treatable condition. Follow up in 2 weeks.
EXAMPLE 4
Comprehensive Focused SOAP Psychiatric Evaluation Template
CC (chief complaint): “I feel amazing — I haven’t slept in three days and I have so many plans.”
Subjective:
CC (chief complaint): “I feel amazing — I haven’t slept in three days and I have so many plans.”
HPI: Ms. K.B. is a 24-year-old single Caucasian female graduate student brought to evaluation by her sister, who reports a 9-day period of concerning behavior change. The patient describes feeling “the best I’ve ever felt,” with markedly elevated and expansive mood. Collateral from her sister indicates the patient has slept only 2–3 hours per night without feeling tired, has been talking rapidly and incessantly, and has started three new business ventures simultaneously. The patient reports racing thoughts, increased goal-directed activity, and heightened self-confidence bordering on grandiosity (“I’m going to change the world”). Her sister reports the patient spent over $7,000 on impulsive purchases and engaged in uncharacteristic sexual behavior. The patient is irritable when her plans are questioned. She has a documented history of two prior major depressive episodes treated with fluoxetine. There is a family history of bipolar disorder in her father. She denies current substance use. She has limited insight into the severity of her behavior.
Substance Current Use: Denies current alcohol or drug use. Reports past experimentation with cannabis in college. No tobacco. No treatment history for substances.
Medical History: No chronic medical conditions. History of two major depressive episodes. Last physical exam 1 year ago, unremarkable.
Current Medications: Fluoxetine 20 mg daily (prescribed by PCP for depression 6 weeks ago). NKDA.
Allergies: NKDA.
Reproductive Hx: G0P0. LMP 1 week ago. Not currently using contraception; counseled on importance given medication considerations.
ROS:
GENERAL: Denies fatigue despite minimal sleep. Denies fever or weight change.
HEENT: Denies headache or visual changes.
CARDIOVASCULAR: Denies chest pain or palpitations.
RESPIRATORY: Denies shortness of breath.
GI: Reports irregular eating due to activity level. Denies nausea.
NEUROLOGICAL: Reports racing thoughts. Denies tremor or seizures.
PSYCHIATRIC: Reports elevated mood, decreased need for sleep, grandiosity, and increased activity.
Objective:
Diagnostic results: Urine toxicology ordered to rule out stimulant intoxication. TSH ordered to rule out hyperthyroidism. CBC, CMP, and pregnancy test ordered prior to mood stabilizer initiation. Young Mania Rating Scale administered, consistent with acute mania.
Physical exam (if applicable): Vital signs: BP 124/78, HR 96, RR 18, Temp 98.5°F, BMI 22.0. General: alert, hyperaroused, brightly dressed in mismatched colorful clothing, restless, difficult to redirect. No acute medical distress.
Assessment:
Mental Status Examination:
The patient is a 24-year-old female appearing younger than her stated age, dressed in bright, mismatched, attention-drawing clothing with heavy makeup. She is intrusive and over-familiar, with intense but poorly modulated eye contact. Psychomotor activity is markedly increased; she is restless and difficult to redirect. Speech is loud, rapid, pressured, and difficult to interrupt. Mood is described as “fantastic.” Affect is expansive and labile, shifting quickly to irritability. Thought process demonstrates flight of ideas and tangentiality. Thought content reveals grandiosity; no suicidal or homicidal ideation; no clear delusions, though grandiose themes are present. No hallucinations reported. Alert and oriented x4. Attention is impaired due to distractibility. Memory grossly intact. Insight is poor; judgment is impaired. Cognition limited by distractibility.
Diagnostic Impression:
1. Bipolar I Disorder, current episode manic, without psychotic features (F31.13) — The patient meets DSM-5-TR criteria for a manic episode: a distinct period of abnormally elevated, expansive, and irritable mood with increased activity lasting more than one week, accompanied by inflated self-esteem/grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, increased goal-directed activity, and excessive involvement in high-risk activities (impulsive spending, sexual indiscretion). The episode causes marked impairment. With a history of prior depressive episodes, this confirms Bipolar I. This is the primary diagnosis.
2. Substance/Medication-Induced Bipolar Disorder (F19.94) — Considered because the recent initiation of fluoxetine (an antidepressant) may have precipitated a manic switch; this is clinically important but the underlying diagnosis remains Bipolar I given the family history and prior episodes.
3. Stimulant Intoxication (F15.929) — Considered given the presentation; ruled out pending urine toxicology to exclude an exogenous cause.
Reflections:
This case illustrated the critical danger of antidepressant monotherapy in patients with underlying bipolar disorder, which can precipitate a manic switch. It reinforced the importance of a thorough history, including family history and collateral information, before prescribing antidepressants for depression. If repeating the evaluation, I would emphasize collateral gathering even more and screen carefully for hypomania in any depressed patient. Ethical and legal considerations include assessing capacity, the possible need for a higher level of care, and balancing autonomy with safety given impaired judgment. A relevant social determinant is the patient’s student status and the impact on her academic and financial future. Health promotion includes psychoeducation for the patient and family about bipolar disorder and the importance of sleep regulation.
Plan:
Discontinue fluoxetine. Initiate a mood stabilizer; given acute mania, consider lithium (after baseline renal/thyroid labs and pregnancy test) or an atypical antipsychotic such as quetiapine or olanzapine for rapid stabilization. Assess need for inpatient admission given impaired judgment, high-risk behavior, and limited insight; if outpatient, ensure close monitoring and family involvement. Order urine toxicology, TSH, CBC, CMP, and pregnancy test. Provide extensive psychoeducation to patient and family. Counsel on contraception given teratogenic risk of mood stabilizers. Follow up within 3–5 days or sooner; provide crisis resources.
EXAMPLE 5
Comprehensive Focused SOAP Psychiatric Evaluation Template
CC (chief complaint): “I can never focus, I’m always losing things, and I’m falling behind at work.”
Subjective:
CC (chief complaint): “I can never focus, I’m always losing things, and I’m falling behind at work.”
HPI: Mr. D.A. is a 27-year-old single biracial male software developer presenting with longstanding difficulties with attention, organization, and impulsivity that he reports have been present “since childhood” but have become more impairing since starting a demanding job. He describes chronic difficulty sustaining attention on tasks, frequent careless mistakes in his code, difficulty organizing projects, and a tendency to procrastinate and miss deadlines. He frequently loses items such as his keys and phone, is easily distracted, and is forgetful in daily activities. He reports internal restlessness, difficulty waiting his turn in conversations, and frequently interrupting others. He recalls being described as a “daydreamer” in elementary school and struggling academically despite high intelligence. He denies a discrete onset, depressed mood as primary, or recent trauma. He reports the symptoms cause significant distress and have led to a recent poor performance review. He denies prior formal evaluation but suspects ADHD after reading about it.
Substance Current Use: Drinks coffee throughout the day to “focus.” Occasional social alcohol use. Denies tobacco or illicit drugs. No treatment history.
Medical History: No chronic medical conditions. No history of head injury. Last physical exam 2 years ago.
Current Medications: None. No known drug allergies.
Allergies: NKDA.
Reproductive Hx: Not applicable; no concerns reported.
ROS:
GENERAL: Denies fatigue, fever, or weight change.
HEENT: Denies headache or visual changes.
CARDIOVASCULAR: Denies chest pain or palpitations; relevant given possible stimulant therapy.
RESPIRATORY: Denies shortness of breath.
NEUROLOGICAL: Reports poor concentration and restlessness. Denies tremor or seizures.
PSYCHIATRIC: Reports inattention, distractibility, impulsivity, and disorganization. Denies depressed or elevated mood.
Objective:
Diagnostic results: Adult ADHD Self-Report Scale (ASRS-v1.1) positive in both inattentive and hyperactive domains. Collateral childhood report and old report cards requested to confirm onset before age 12. TSH ordered to rule out thyroid dysfunction. Baseline ECG considered prior to stimulant initiation.
Physical exam (if applicable): Vital signs: BP 122/76, HR 80, RR 16, Temp 98.6°F, BMI 24.2. General: alert, cooperative, fidgety, taps foot and shifts frequently. No acute distress. Cardiovascular exam noted as baseline given potential stimulant therapy.
Assessment:
Mental Status Examination:
The patient is a 27-year-old male appearing his stated age, casually and appropriately dressed and well groomed. He is friendly and cooperative with good eye contact, though visibly fidgety, tapping his foot and shifting in his seat. Psychomotor activity is mildly increased. Speech is normal in rate, volume, and articulation, though occasionally he interrupts. Mood is described as “frustrated.” Affect is full range and appropriate. Thought process is logical though occasionally tangential, requiring redirection. Thought content reveals no suicidal or homicidal ideation, no delusions. No perceptual disturbances. Alert and oriented x4. Attention and concentration are impaired during testing (difficulty with serial sevens). Memory grossly intact. Insight is good; judgment is intact. Cognition above average overall despite attentional difficulties.
Diagnostic Impression:
1. Attention-Deficit/Hyperactivity Disorder, combined presentation (F90.2) — The patient meets DSM-5-TR criteria with multiple symptoms of both inattention (careless mistakes, difficulty sustaining attention, poor organization, losing items, distractibility, forgetfulness) and hyperactivity-impulsivity (restlessness, interrupting, difficulty waiting). Several symptoms were present before age 12, occur in multiple settings (work and home), and cause significant functional impairment. This is the primary diagnosis, pending confirmation of childhood onset.
2. Generalized Anxiety Disorder (F41.1) — Considered because anxiety can produce concentration difficulties and restlessness; however, the patient denies pervasive worry, and symptoms are lifelong and attention-specific rather than worry-driven.
3. Mild Neurocognitive concerns / Substance (Caffeine) effects — Considered given high caffeine intake, which can mimic or worsen restlessness and inattention; caffeine reduction and confirmation of childhood onset help differentiate.
Reflections:
This case emphasized the importance of establishing childhood onset and obtaining collateral information when diagnosing adult ADHD, as the disorder cannot be diagnosed de novo in adulthood. It also highlighted the need to rule out anxiety and substance (caffeine) effects that can mimic the presentation. If I were to repeat the evaluation, I would gather collateral and standardized childhood data before the visit. Ethical and legal considerations include the responsible prescribing of controlled stimulant medications, screening for diversion risk, and cardiovascular safety. A relevant social determinant is workplace accommodation and access to support. Health promotion includes coaching on organizational strategies, sleep, exercise, and caffeine moderation.
Plan:
Confirm childhood onset via collateral history and prior records before finalizing diagnosis. If confirmed, discuss treatment options. Consider a first-line stimulant such as extended-release methylphenidate or amphetamine salts after baseline cardiovascular assessment, or atomoxetine as a non-stimulant alternative. Refer for ADHD-focused cognitive behavioral therapy and organizational coaching. Counsel on caffeine reduction and sleep hygiene. Order TSH and obtain baseline ECG if stimulant chosen. Educate on controlled-substance handling and monitoring. Follow up in 2–4 weeks to assess response and side effects.
