Soap Note on ADHD
Name: Date:
Sex: Male Age: 6
Historian: Mother
CC: “My son makes careless mistakes in school work and other activities.”
Child profile:
Child is able to dress herself and feed herself. He is also able to do most of her activities of daily
living on her own. He speaks clearly, and enjoys telling stories. He also enjoys playing with his
age manes and his friends and he is able to hop and skip. Child can also print numbers and
letters. However, he has challenges paying attention to what he is doing or what he is told. Many
are the instances he does not complete his homework. Child has problems organizing tasks and
he keeps losing his toys and his pencils.
A 6 years old African American boy is brought to the office by his mother who reports that the
boy makes careless mistakes in school work and other activities at home. She adds that the boy
has also been having difficulties paying attention to activities that he is involved in, does not
seem to listen when spoken to and does not follow through with instructions. She says the his
teacher has reported these symptoms two times previously and she has decided to bring him to
hospital to be checked since she has tried to talk to the child and even punish the child but he
does seem to change his unruly behaviors. Mother sways that the boy is thought of by other
people to be having. Mother also adds that the child has been having these symptoms since he
was 2 years and she thought it was part of his developmental mile ones but since the symptoms
have been persistent, she thinks her son has a problem. Mother says that the child has never been
diagnosed with any chronological disorder


Family History:
Maternal aunt was diagnosed with ADHD when he was 5 years old. Mother has asthma and
father has no known chronic ailment. Siblings are on good health condition.
Social History: Patient is 6 years old and lives with her biological parents and two elder siblings.
Her parents own a gun but keep it in a safe in the house and out of reach of children. Mother says
that she takes wine and the patient’s father also takes wine occasionally but she denies smoking,
vaping and drug abuse. Child’s physical activities are monitored to avoid injuries and he sits on
his child booster seat at the rear seat fop the car.
General: Denies fatigues, chills, body aches,
malaise, fever, night sweats, sudden changes in
energy levels and sudden changes in weight.
Cardiovascular: Denies chest tightness, pain,
tenderness, fast and slow heart rates and
Respiratory: Denies wheezes, shortness of
breath, consistent coughs, and breathing
difficulties while resting.
Neurological: Denies cases of fainting, loss of
consciousness, syncope, weakness, and
headaches. Reports difficulties concentrating
and paying attention.
Heme/Lymph/Endo: Denies changes in energy
levels, sudden increase or decrease in weight,
heat or cold intolerance, blood transfusion, and
Psychiatric: Reports inattentiveness, child not
completing his homework and having
problems organizing his work, child making
careless mistakes and seems not to listen when
he is being spoken to, and does not follow
through with instructions.
Weight: 46
BMI: 15.3 kg/m2
BP: 103/ 72 Temp: 98.6
Height: 3’ 10” Pulse: 97 Resp: 22
Weight-for-age percentile: Height-for-age percentile: BMI-for-age percentile: 47%
Soap Note on ADHD 4
52% 61%
General Appearance: Patient is a healthy looking and well nourished child. He plays with his
toys but loses attention on his games very fast and diverts to other things like giving his mother
stories or showing things.
Cardiovascular: Heart rates and rhythm are regular and murmurs and extra sounds are heard.
Pulse is normal throughout and capillaries refill in 2 seconds.
Respiratory: Wheezes are absent and respirations are easy and regular.
Neurological: Gait is normal, balance is stable, posture is erect, speech is clear and tone is good.
Psychiatric: Inattentiveness is observed as the patient starts a task or a game and gets distracted
easily orb starts another one shortly after. He also seems not to listen as we speak to him.
In house lab tests:
Neuropsychological testing: Patient has deficits in executing functions where he is expected to
prioritize, plan, inhibit behavior and attend to as well as processing speed and processing speed.
Pediatric Assessment tool: Vital signs and the height of the patient are appropriate for the age of
the patient. Diet: The patient’s regular diet comprises of cereals, fruits, beef and chicken, and
milk. Dental development: Patient’s two milk teeth have been removes and dental development
is appropriate for the age of the child. Behavioral: Patient seems not to listen when he is spoken
to, he has problems concentrating on a task for long, arranging his tasks in order and he does not
follow through with instructions.
Differential Diagnosis:
F80.9 – Learning/language disorder: This disorder is characterized by most of the symptoms that
patient presented with such difficulties paying attention to activities, misplacing things, child
looking like they are not listening while they are being spoken to, and child having challenges
arranging his tasks in order. However, Neuropsychological testing revealed that child has
inattention in all subjects but not only in a particular subject. These results were used to rule out
the diagnosis of Learning/language disorder.
F91. 3 – Oppositional defiant disorder: This is a disorder that is characterized by ore hostile

Soap Note on ADHD 5
behaviors such as open defiance, rebellion and anger (Turner, Hu, Villa, & Nock, 2018). In this
disorder, most behaviors are directed to a particular figure. However, patient did not present with
hostile behaviors and his behaviors were not direct at a particular figure.
F91.9 – Conduct disorder: This disorder is characterized by a repeat pattern of violating the rights
of others or the societal rules. The behaviors associated with disorders include destruction of
properties, aggressions that hurts others, stealing and lying. Patient presented with unruly
behaviors but they were not as extreme as the behaviors associated with conduct disorder hence
the diagnosis was ruled out.
Primary Diagnosis:
F90. 0 – Attention-deficit/hyperactivity disorder (ADHD) in children: This is a chronic disorder
that affects most children and in often cases, it progresses to adulthood (Sayal at al., 2018). It
includes a combination of persistent problems such as hyperactivity, difficulties sustaining
attention and impulsive behavior. The condition also has three subtypes which are predominantly
inattentive, Predominantly hyperactive/impulsive and combined. Patient presented with
symptoms of predominantly inattentive subtype of ADHD such as difficulties paying attention to
a particular task, problems with organization of tasks, careless mistakes, loosing staff often and
looking like a child is not listening when a person talks to him. . Neuropsychological testing was
also used to eliminate other neuropsychological disorders and it results confirmed the primary
diagnosis as ADHD.
Treatment Plan
The first line of treatment for children who are diagnosed with ADHD and have no stimulant
abuse potential or prominent anxiety symptoms is a stimulant and psychoeducation.
Prescribed Methylphenidate (Metadate CD) Initial, 20 mg PO qAM before breakfast. May be
increased in 10- to 20-mg increments, not to exceed 60 mg/day (Feldman, Charach & Bélanger,
Soap Note on ADHD 6
Mother was advised about the symptoms, typical cause of the disorder and treatment options.
Mother was also advised on individualized education and referred to support and advocacy
organizations for children and children with ADHD. Online resources on ADHD were also
recommended and mother was issued with handouts on ADHD.
Feldman, M. E., Charach, A., & Bélanger, S. A. (2018). ADHD in children and youth: Part 2—
Treatment. Paediatrics & child health, 23(7), 462-472.
Sayal, K., Prasad, V., Daley, D., Ford, T., & Coghill, D. (2018). ADHD in children and young
people: prevalence, care pathways, and service provision. The Lancet Psychiatry, 5(2),
Turner, B. J., Hu, C., Villa, J. P., & Nock, M. K. (2018). Oppositional defiant disorder and
conduct disorder.