Attention Deficit Hyperactivity Disorder follow-up

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Returns for ‍ADHD follow-up

Last visit was ‍ ‍months ago

Progress since last visit: ‍unchangedimproveddeterioratedvariableresolved



Current symptoms:

‍inattention

‍hyperactivity

‍impulsivity

‍difficulty focusing

‍forgetfulness

‍difficulty completing tasks

‍difficulty organizing tasks

‍frequent mistakes

‍easily distracted

‍fidgeting

‍restlessness

‍excessive talking

‍interrupting others

‍difficulty waiting turn



Contributing factors:

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



Medications

‍stimulants, ‍non-stimulants, ‍antidepressants

Change at last visit: ‍ ‍introducedincreased, ‍effectiveineffective, ‍adverse effects

Adherence: ‍goodaveragepoor



Other interventions tried: ‍ ‍none, ‍behavioral therapy, ‍social skills training, ‍parenting skills training, ‍school accommodations, ‍effectiveineffective



Labs: TSH: ‍ ‍normal, Hb: ‍ ‍normal





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, ‍well-controlled

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