Issues:
1. ADHD
2. Anxiety
Medications:
1. Methylphenidate 10mg, take 1 tablet in the morning.
2. Melatonin 3mg, take 1 tablet at night.
Ceased Medications:
* None
Teams/Allied Health:
* Psychologist
I had the pleasure of reviewing Thomas, a 7-year-old boy, accompanied by his mother, Sarah.
Thomas attends St. Mary's Primary School and is in Year 2. He is making good progress in most subjects, particularly enjoying Maths. Sarah reports that the methylphenidate is effective during the school day, helping him to focus and reduce impulsivity. There have been no reports of behavioural challenges or suspensions. Thomas's grades are good.
Thomas has reported no side effects from his medication.
Thomas has not tried any previous medications.
Thomas's sleep is generally good, he goes to bed at 8:00 pm and wakes up at 7:00 am. He has been taking melatonin to help him fall asleep. Sarah reports that Thomas has been having some difficulty falling asleep recently, taking up to an hour to fall asleep.
Thomas is currently seeing a psychologist for therapy. He has no other potential conditions. He is a very active and sociable child.
Thomas attends football training twice a week.
Thomas has been experiencing increased anxiety, particularly around school and social situations. He is also having some difficulty falling asleep.
ADHD monitoring forms were completed by Sarah, and they indicate a significant improvement in attention and hyperactivity since starting medication.
Physical examination revealed a weight of 25 kg (50th centile) and a height of 125 cm (75th centile).
Investigations: None
Impression: Thomas, aged 7 years, presents with ADHD and anxiety. Treatment optimization is ongoing.
Plan:
1. Continue methylphenidate 10mg daily.
2. Continue melatonin 3mg nightly.
3. No screens 1hr prior to bed, trial meditation smiling minds/headspace or audio book. If taking >1hr to fall asleep can continue melatonin. Trial off melatonin every 2 month - every 2nd night for 1 week and then stop. Restart if taking >1hr to fall asleep despite good sleep hygiene.
4. Review in 3 months.
Issues:
[list all medical issues] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as a numbered list.)
Medications:
[list all current medications with dose and instructions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as a numbered list.)
Ceased Medications:
[list medications that have been stopped with reason for cessation, including any changes made to dose during appointment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points.)
Teams/Allied Health:
[list specialists, psychology, OT, speech pathology, or other allied health professionals] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points.)
[write introductory paragraph starting with 'I had the pleasure of reviewing' and describing patient name, age in years and months, and who accompanied them] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write in full sentences as a paragraph. Use the patient and parents names to identify who said what or who observed what in the consult.)
[summarize patient's school name, grade, progress and challenges, commenting on efficacy of stimulant medication throughout the school day where applicable, any behavioural challenges, suspensions, aggression, anxiety at school if applicable, any learning supports being received if applicable, grades and favourite subject if applicable] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write in full sentences as a paragraph. Use the patient and parents names to identify who said what or who observed what in the consult. Do not write as a list.)
[report on any side effects experienced by the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write in full sentences as a paragraph. Use the patient and parents names to identify who said what or who observed what in the consult. Do not write as a list.)
[describe any previous medications trialled and reason why stopped] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write in full sentences as a paragraph.)
[assess patient's sleep patterns and dietary habits, must include information about sleep] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write in full sentences as a paragraph. Use the patient and parents names to identify who said what or who observed what in the consult. Do not write as a list.)
[describe engagement with any therapies, assessment of other potential conditions, and relevant traits or characteristics] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write in full sentences as a paragraph.)
[describe any extra-curricular activities] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write in full sentences as a paragraph.)
[describe any new issues or any medical issues mentioned including any concerns with sleep] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write in full sentences as a paragraph.)
[describe any anxiety and assess patient's mood and mental health] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write in full sentences as a paragraph. Use the patient and parents names to identify who said what or who observed what in the consult. Do not write as a list.)
[describe any results on ADHD monitoring forms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write in full sentences as a paragraph.)
[document physical examination findings including centiles after weight and height measurements] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write in full sentences as a paragraph.)
[document investigations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write in full sentences as a paragraph.)
Impression:
[provide summary of patient's condition, starting with name and then age, and treatment optimization] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write in full sentences as a paragraph.)
Plan:
(Write as a numbered list with each item on its own line.)
[outline the treatment plan including any medication adjustments and follow-up] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.)
[describe medication plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.)
[provide sleep advice if discussed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Include as numbered item in plan. If sleep hygiene advice was given, print: "No screens 1hr prior to bed, trial meditation smiling minds/headspace or audio book. If taking >1hr to fall asleep can continue melatonin. Trial off melatonin every 2 month - every 2nd night for 1 week and then stop. Restart if taking >1hr to fall asleep despite good sleep hygiene.")
[provide dietary advice if discussed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.)
[describe any assessments or feedback from school] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.)
[specify follow-up timeframe] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.)
(Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)