NUR 676 Module 8 SOAP Note Example

SOAP Note: Evaluating and Treating Attention-Deficit Hyperactivity Disorder in a 30-Year-Old Adult

[Student Name]

Southern New Hampshire University

NUR 676: Primary Care for Mental Health

Module Eight SOAP Note

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

SOAP Note: Evaluating and Treating Attention-Deficit Hyperactivity Disorder in a 30-Year-Old Adult

Adults increasingly ask primary care clinicians whether they have ADHD, often after learning about it online or from someone they know. Some have lifelong ADHD that was never recognized; others have attention problems caused by anxiety, depression, poor sleep or substance use. Because stimulant medications are effective but carry risks of misuse and cardiovascular effects, the evaluation must be careful in both directions. Alex, 30, came to a composite community clinic asking to be tested. This SOAP note documents the evaluation and plan. It argues that a validated screen, confirmation of childhood onset and impairment with collateral information, a search for conditions that mimic ADHD and a treatment plan with safeguards allow primary care to diagnose and treat adult ADHD responsibly.

Subjective

Chief concern: "I think I might have ADHD. I can't keep up at work."

History of present illness: Alex reports lifelong difficulty staying focused on tasks he finds boring, losing track of deadlines, misplacing keys and phone daily, starting projects without finishing them and interrupting others in meetings. He has been let go from two jobs for missed deadlines. He describes restlessness and difficulty sitting through long meetings. His mother, reached by phone with his permission, recalls that teachers described him as bright but disorganized, often daydreaming and not finishing work, beginning in second grade, and his old report cards confirm this. His partner reports that he forgets appointments and bills. He sleeps about six hours on weeknights, snores occasionally but does not gasp, and reports no persistent low mood or excessive worry. He uses cannabis two or three evenings a week to unwind and drinks socially. He has no history of heart disease, fainting or palpitations, and no family history of sudden cardiac death.

Past history: no psychiatric diagnoses. Medications: none.

Objective

Blood pressure 124/78, pulse 76, body mass index 25. Examination normal, including cardiovascular examination. Adult ADHD Self-Report Scale Part A: five of six items in the range that suggests ADHD. PHQ-9 score 4; GAD-7 score 4. AUDIT-C score 3. A check of the state prescription drug monitoring program showed no controlled substance prescriptions.

Assessment

1. Attention-deficit hyperactivity disorder, combined presentation. Kessler et al. (2005) developed the Adult ADHD Self-Report Scale screener for the World Health Organization, selecting six questions from the full symptom checklist that best predicted a clinical diagnosis in a community sample; it is intended to identify adults who need a full evaluation rather than to make the diagnosis itself. Alex's positive screen was followed by a clinical interview confirming at least five inattentive and five hyperactive-impulsive symptoms, present before age 12 by collateral report, occurring at work and at home and causing clear impairment.

Faraone et al. (2021), speaking for an international ADHD federation's consensus panel, summarized evidence that ADHD often persists into adulthood, that diagnosis requires symptoms beginning in childhood and impairment across settings and that conditions such as anxiety, depression, substance use and sleep problems frequently coexist or mimic it. Alex's low depression and anxiety scores, absence of symptoms beginning only in adulthood and consistent childhood history argue against these as primary explanations. His cannabis use and short sleep may worsen attention and will be addressed, but they do not account for symptoms present since early childhood.

Choosing Treatment

Cortese et al. (2018) conducted a network meta-analysis comparing medications for ADHD across children, adolescents and adults. Considering both efficacy and tolerability, they concluded that the evidence supported methylphenidate as the preferred first choice for children and adolescents and amphetamines for adults, for short-term treatment, while noting limited long-term data. Nonstimulants such as atomoxetine are alternatives, especially when misuse risk is a concern.

Options were discussed with Alex, including a long-acting stimulant, a nonstimulant, skills-based coaching and cognitive behavioral therapy for adult ADHD. Because his cannabis use is modest and he has never had a substance use disorder, a long-acting stimulant was judged appropriate with safeguards. He chose lisdexamfetamine, a prodrug with a lower potential for misuse by injection or snorting, starting at 30 mg each morning.

Plan and Safeguards

Lisdexamfetamine 30 mg each morning, with possible increases every one to two weeks based on benefit and side effects. A controlled substance agreement was reviewed and signed, covering one prescriber, no early refills, secure storage and never sharing medication, and the prescription monitoring program will be checked before each prescription. Alex was counseled about side effects, including reduced appetite, insomnia, elevated heart rate and blood pressure and irritability, and told to seek care for chest pain, palpitations or fainting. He agreed to stop cannabis while the dose is being established and to aim for seven hours of sleep. ADHD skills coaching with the clinic's therapist, focused on organization and time management. Follow-up in two weeks with blood pressure, pulse, weight and a symptom rating scale, then monthly until stable and every three months thereafter.

Work, Driving and Follow-Through

Adult ADHD affects more than work performance. People with untreated ADHD have higher rates of traffic accidents, financial problems and relationship strain, and Alex's partner described late bills and missed appointments. The plan therefore includes practical supports alongside medication: a shared digital calendar with his partner, automatic bill payments and a habit of placing keys and phone in the same spot each evening. He was told that he may notice improvement in focus within days of starting the stimulant, but that building routines takes longer and is what the coaching sessions are for. He asked whether to tell his employer; he was told that disclosure is his choice and that he may request reasonable accommodations, such as written instructions or a quieter workspace, if he chooses. Driving was discussed, since ADHD increases crash risk, and he was encouraged to avoid phone use while driving and to take the medication consistently on days he drives.

Conclusion

Alex's request could have ended in an automatic prescription or an automatic refusal. Instead, a validated screen led to a full evaluation that confirmed lifelong ADHD with collateral history, considered conditions that mimic it and identified modifiable contributors. A stimulant chosen with network meta-analysis evidence, paired with a controlled substance agreement, monitoring and coaching, offers effective treatment with appropriate safeguards.

References

Cortese, S., Adamo, N., Del Giovane, C., Mohr-Jensen, C., Hayes, A. J., Carucci, S., Atkinson, L. Z., Tessari, L., Banaschewski, T., Coghill, D., Hollis, C., Simonoff, E., Zuddas, A., Barbui, C., Purgato, M., Steinhausen, H.-C., Shokraneh, F., Xia, J., & Cipriani, A. (2018). Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: A systematic review and network meta-analysis. The Lancet Psychiatry, 5(9), 727-738. https://doi.org/10.1016/S2215-0366(18)30269-4

Faraone, S. V., Banaschewski, T., Coghill, D., Zheng, Y., Biederman, J., Bellgrove, M. A., Newcorn, J. H., Gignac, M., Al Saud, N. M., Manor, I., Rohde, L. A., Yang, L., Cortese, S., Almagor, D., Stein, M. A., Albatti, T. H., Aljoudi, H. F., Alqahtani, M. M., Asherson, P., . . . Wang, Y. (2021). The World Federation of ADHD international consensus statement: 208 evidence-based conclusions about the disorder. Neuroscience & Biobehavioral Reviews, 128, 789-818. https://doi.org/10.1016/j.neubiorev.2021.01.022

Kessler, R. C., Adler, L., Ames, M., Demler, O., Faraone, S., Hiripi, E., Howes, M. J., Jin, R., Secnik, K., Spencer, T., Ustun, T. B., & Walters, E. E. (2005). The World Health Organization adult ADHD self-report scale (ASRS): A short screening scale for use in the general population. Psychological Medicine, 35(2), 245-256. https://doi.org/10.1017/S0033291704002892