Pediatric Behavioral Health (Intake / Follow Up)

Summary: - The patient, a 10-year-old male, presents with symptoms of ADHD, including inattention and hyperactivity. Diagnosis: ADHD, Combined Presentation. Initial treatment plan includes medication management and behavioural therapy. - Strengths: Intelligent, enjoys school. Challenges: Difficulty focusing, impulsive behaviours. Short-term goals: Improve focus in class, reduce impulsive behaviours. Long-term goals: Achieve academic success, develop coping mechanisms. Chief Complaint: The patient's main reason for seeking care is difficulty focusing in school and exhibiting impulsive behaviours, as reported by the parents. History of Present Illness (HPI): - Symptoms began approximately 6 months ago, with increasing difficulty focusing in class and at home. The patient also exhibits impulsive behaviours, such as interrupting others and difficulty waiting his turn. Severity has increased over time. - Triggering events include stressful situations at school and home. Factors contributing to symptoms include family history of ADHD. - The patient has not attempted any self-management or interventions. Medications: - Current Medications: Methylphenidate 10mg, taken once daily in the morning for ADHD. - Past Medications: None. - Over-the-Counter Medications/Supplements: None. Medication Access: - The patient has pharmacy access and insurance coverage. No barriers to obtaining medications. - Medication adherence is good. No challenges reported. Social History: - Living Situation: Lives with both parents and one sibling in a stable home environment. - Relationships: Good relationships with family and peers. - Education: Attends the 5th grade and is performing at grade level, but struggles with focus in class. - Activities: Enjoys playing video games and participating in sports. Family History: - Father diagnosed with ADHD. Child Developmental History: - Prenatal and Birth History: Unremarkable prenatal history. Normal vaginal delivery. - Developmental Milestones: Met all developmental milestones on time. - Behavioral/Emotional Development: Generally happy and well-adjusted, but exhibits some emotional outbursts when frustrated. Childhood Environment (Parents and Dwelling): - Parents are supportive and involved in the patient's care. The family structure is stable. - The patient's upbringing has been supportive, with a focus on education and extracurricular activities. Conner’s Behavioral Rating Scale: - Inattention: T-score of 75, significant difficulties with attention and focus. - Hyperactivity/Impulsivity: T-score of 70, elevated levels of hyperactivity and impulsivity. - Other subscales and results: Oppositional T-score of 65. Trauma/Abuse History: - No history of trauma, abuse, or neglect. - Supportive family and school environment. Psychiatric History: - Diagnoses: ADHD, Combined Presentation. - Treatments: Currently on Methylphenidate 10mg. No prior therapy or hospitalizations. - Suicidality/Self-Harm: No history of suicidal ideation or self-injurious behaviours. Substance Use: - No substance use. - No history of substance use disorder or treatment. Sleep: - Sleeps approximately 9 hours per night. No reported sleep disturbances. Tests and Scores: - Conner's Rating Scales completed by parents and teacher. Mental Status Exam: - Appearance: Well-groomed and appropriately dressed. - Behavior: Cooperative and engaged during the assessment. - Mood/Affect: Generally happy and appropriate affect. - Thought Process/Content: Coherent and logical thought process. - Cognition/Insight/Judgment: Age-appropriate cognitive abilities. Good insight and judgment. Assessment: - ADHD, Combined Presentation. Moderate severity of symptoms. Key findings include significant inattention, hyperactivity, and impulsivity. Safety Assessment: - No suicidal ideation or self-harm risk. - Protective factors include a supportive family and school environment. Safety planning is not required. DSM-5-TR Codes: - 314.01 (ADHD, Combined Presentation) Plan: - Medications: Continue Methylphenidate 10mg daily. Monitor for side effects and efficacy. - Therapy: Recommend behavioural therapy with a therapist specializing in ADHD. - Interventions: Discuss with the school to implement classroom accommodations, such as preferential seating and extended time for assignments. - Follow-Up: Schedule a follow-up appointment in 4 weeks to assess medication effectiveness and review progress. Follow-Up Email: - A summary of the visit, recommendations, and contact information for questions will be sent to the parents. Billing Codes: - 90791, 99213 To-Dos: - Schedule a follow-up appointment in 4 weeks. - Send a summary of the visit and recommendations to the parents. - Communicate with the school regarding classroom accommodations. - Refill medication as needed.