I had the pleasure of seeing Oliver Twist accompanied by Mrs. Twist on 1 November 2024. As you know, he is a 7-year-old M referred for concerns regarding inattention, hyperactivity, and impulsivity.
Reason for referral and history of the issue and symptoms, include details of ADHD symptoms and how they affect the child at home and at school, discuss interventions that have been tried so far, and investigations: Oliver presents with significant difficulties in maintaining focus, particularly during classroom activities. He frequently fidgets, struggles to remain seated, and often interrupts others. At home, he has trouble completing chores and following instructions. Mrs. Twist reports that these behaviours have been present for at least a year and are impacting his academic performance and social interactions. Previous interventions include behavioural therapy and parent training, with limited success. No formal investigations have been completed.
School: St. Andrews Primary School
Grade: 2nd Grade
Evaluation tools:
Results of SNAP IV questionnaires as completed by parents and teachers, include whether they are significant for diagnosis of ADHD: SNAP-IV questionnaires completed by both parents and teachers indicate significant symptoms of inattention and hyperactivity-impulsivity, strongly suggestive of ADHD.
Patient self report: Oliver reports feeling restless and having difficulty concentrating.
Teacher rating scales and comments: Teacher reports that Oliver is easily distracted, struggles to follow directions, and often disrupts the class.
Associated concerns: Oliver also exhibits some signs of anxiety, particularly in social situations.
Academics and any academic concerns: Oliver is struggling academically, particularly in reading and maths. He is not meeting grade-level expectations.
Screening for concurrent issues:
Social: Social interactions are atypical; Oliver struggles to make and maintain friendships.
Anxiety symptoms: Oliver reports feeling worried and anxious in social situations.
Sleep:
Sleep issues: Oliver has difficulty falling asleep and often wakes up during the night.
Hearing and Vision:
Status of testing, any abnormalities found: Vision and hearing screening completed at school, no abnormalities found.
Past Medical History:
Birth History: Normal vaginal delivery.
Early developmental milestones:
Developmental milestone status: All developmental milestones were met on time.
Hospitalizations: None.
Surgeries: None.
Allergies: None.
Medications: None.
Immunizations: Up to date.
Family History:
Family history of neurodevelopmental/psychiatric conditions: Father has a history of ADHD.
Social History:
Living situation: Lives with both parents.
Review of Systems:
Review of systems findings: Otherwise unremarkable.
Physical Examination:
General appearance: Alert and active.
Behavioural observations: Fidgety and restless during the examination.
HEENT: Tympanic membranes clear, oropharynx clear, tonsils not enlarged.
Resp: Clear to auscultation.
CVS: Regular rate and rhythm.
Abdo: Soft, non-tender.
Neuro: Grossly intact.
Skin: Normal.
Assessment and Plan:
Summary of presenting issue and working diagnosis: ADHD, combined presentation.
Plan for investigation and management: Initiate medication trial with methylphenidate. Schedule follow-up appointment in one month to assess response and side effects. Recommend further psychological evaluation.
Followup plan: Schedule follow-up appointment in one month.
I had the pleasure of seeing [patient name] accompanied by [accompanying person] on [date]. As you know, [he/she/they] is a [age] [M/F/X] referred for [reason for referral].
[Reason for referral and history of the issue and symptoms, include details of ADHD symptoms and how they affect the child at home and at school, discuss interventions that have been tried so far, and investigations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
School: [Insert school] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Grade: [Insert grade] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Evaluation tools:
[Results of SNAP IV questionnaires as completed by parents and teachers, include whether they are significant for diagnosis of ADHD] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Patient self report ] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Teacher rating scales and comments ] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Associated concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Academics and any academic concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Psychoeducational assessment results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Screening for concurrent issues:
Social:
[Are social interactions typical or atypical ] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Sensory processing/regulation issues:
[Food] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Smell] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Noise] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Clothing] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Touch] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Sensory seeking behaviours] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Anxiety symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Tics:
[Stereotypic movement status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Sleep:
[Sleep issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Bowel/Bladder issues:
[Issues with toilet training, with enuresis, with constipation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Screen Time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Hearing and Vision:
[Status of testing, any abnormalities found] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Overall Temperament ](Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Past Medical History:
[Pregnancy History] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[In Utero exposures] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Birth History] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Early developmental milestones:
[Language] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Gross Motor] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Fine Motor] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Social] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Developmental milestone status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Hospitalizations: [Hospitalizations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Surgeries: [Surgeries] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Allergies: [Allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Medications: [Medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Immunizations: [Immunization status ] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Family History:
[Parents ages and health] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Siblings ages and health] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Family history of dysrhythmia or sudden cardiac death] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Family history of neurodevelopmental/psychiatric conditions ](Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Family history of medical conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Social History:
[Living situation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Parents occupations ](Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Confidential SHADES assessment reveals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Strengths] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Gender identity and preferred pronouns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Sexual orientation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Friendships and peer group] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Trauma history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Bullying history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Substance use history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Eating disorder history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Mood symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Review of Systems:
[Review of systems findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Physical Examination:
[General appearance] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Behavioural observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
HEENT: tympanic membranes [tympanic membrane findings (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)], oropharynx [oropharynx findings (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)], tonsils [tonsil findings (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)], [lymphadenopathy findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Resp: [Respiratory findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
CVS: [Cardiovascular findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Abdo: [Abdominal findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Neuro: [Neurological findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Skin: [Skin findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
MSK:
[Dysmorphisms or physical anomalies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Assessment and Plan:
[Summary of presenting issue and working diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Differential Diagnosis and pertinent negatives] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Plan for investigation and management] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[List other issues, likely diagnoses, and plans for investigation and management] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Followup plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
