Attention Deficit Hyperactivity Disorder

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of ‍inattention

Specific difficulties: ‍ ‍

Impact on daily activities is ‍absent, affecting ‍daily activitiessocial lifeworkstudiesfamilypersonal relationships

Worsening factors: ‍nonestress

Alleviating factors: ‍none, ‍effectiveineffective



Associated symptoms: *Try using right-click for negatives*

‍difficulty concentrating

‍difficulty planning or solving problems

‍distractibility

‍difficulty finding words

‍agitation

‍irritability

‍anxiety

‍depression

‍social withdrawal

‍sleep disturbances

‍loss of appetite



Contributing factors:

no history of: ‍learning disabilities, ‍anxiety disorders, ‍depression, ‍bipolar disorder, ‍substance use disorder

no family history of: ‍ADHD





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Metrics: weight: ‍ ‍kglbs, height: ‍ cm, waist: ‍ cm, BMI: ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Neurologic: cranial nerves ‍intact, strength ‍intact 5/5, sensation ‍intact, reflexes ‍intact 2+, cerebellar function ‍intact, gait ‍steady

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought ‍organized, ‍suicidal ideation, judgment ‍good





ASSESSMENT:

‍Attention Deficit Hyperactivity Disorder ‍likelysuspectedpossible

DDx: learning disorders, depression, anxiety disorders, personality disorders, substance use disorders, sleep disorders, neurocognitive disorders, oppositional defiant disorder, conduct disorder, autism spectrum disorder, thyroid disease, hearing problems, vision problems, epilepsy, brain injury, medication side effects, environmental toxins, lead exposure, iron deficiency anemia, child abuse or neglect, premature birth complications





PLAN:

Investigations:

- Blood work: ‍CBC, ‍TSH, ‍LFTs, ‍creatinine, ‍electrolytes if medication started

- ECG if medication started

- Monitor blood pressure and heart rate if medication started

- Monitor growth if medication started

Treatments:

- Psychoeducation about ADHD

- Behavioral therapy

- Parenting skills training

- School accommodations

- Sleep hygiene

- ‍Stimulants, ‍non-stimulants

- ‍Antidepressants

Further care:

- Referral to neuropsychologist

- Referral to psychiatrist

- Referral to social worker

- Follow-up in ‍ ‍weeksmonths