paedrv

[241101] James Smith cc: Dr. Emily Carter Problem List: 1. ADHD (F90.0) 2. Anxiety (F41.9) Medications: 1. Methylphenidate 10mg twice daily 2. Sertraline 50mg daily Ceased Medications: - Nil Support Team: - Sarah Jones, Psychologist, ABC Therapy, weekly sessions. Parents: - John and Mary Smith. Separated parenting arrangement. School: Oakwood Primary School Grade: Year 5 2024 Teacher: Mr. David Brown I had the pleasure of reviewing James who is now 10 years and 6 months old on the 01/11/2024. They attended with John Smith who is their father. The appointment was in clinic rooms. School Progress: James is experiencing difficulties with focus and attention in class, as reported by Mr. Brown. He is struggling to complete tasks and is easily distracted. Methylphenidate appears to be helping with focus, but the effects are wearing off by mid-afternoon. James reports feeling anxious about school, particularly tests. Home Progress: James reports feeling anxious at home, especially when his parents argue. He struggles to complete homework and often becomes frustrated. He has been experiencing some difficulties with sleep and has been waking up during the night. His father reports that James has been experiencing some aggressive outbursts. Allied Therapies and External Supports: James is currently seeing Sarah Jones, a psychologist at ABC Therapy, for weekly sessions. The goals of therapy are to manage anxiety and improve coping skills. He is also attending occupational therapy sessions twice a month to help with sensory processing issues. Mental Health: James presented with symptoms of anxiety and ADHD. He reports feeling worried and overwhelmed at times. He also reports feeling sad. He is currently taking sertraline for his anxiety. Sleep: James has been experiencing some difficulties with sleep. He reports waking up during the night. He goes to bed at 9pm and wakes up at 7am. Diet: James has a good appetite and eats a balanced diet. His weight is within a healthy range. Toileting: James has no current toileting issues. Side Effects of Medications: James reports no significant side effects from his medications. Examination: Weight – 35 kg Height – 140 cm BMI – 17.9 kg/m2 BP – 110/70 mmHg Examination findings were unremarkable. HSDNM CC. Summary: James is experiencing difficulties with ADHD and anxiety. He is struggling with focus at school and is experiencing some difficulties with sleep and aggression at home. He is responding well to medication, but the effects are wearing off by mid-afternoon. Plan: - Increase methylphenidate to 15mg twice daily. - Continue sertraline 50mg daily. - Review in 3 months. - Encourage James to continue with therapy. - Refer to sleep specialist.