General Paediatric Consult

Problem List: 1. Attention Deficit Hyperactivity Disorder (ADHD), combined presentation 2. Mild anxiety 3. Eczema Medications: 1. Methylphenidate 10mg modified release, once daily in the morning. 2. Cetirizine 5mg, once daily as needed for allergies. Discontinued Medications: 1. Fluoxetine 10mg daily, discontinued 3 months ago due to inadequate response and increased agitation. Presenting Complaint: Patient presented with concerns regarding ongoing difficulties with attention, hyperactivity, and impulsivity impacting his academic performance and social interactions. His parents also noted increased anxiety, particularly before school, and occasional defiant behaviours at home. History of Presenting Complaint: "I had the pleasure of reviewing" David Miller, 8 years "who attended with" his mother, Sarah Miller, and his father, John Miller. Sarah Miller described David's difficulties with sustaining attention during school tasks, frequently losing focus and often making careless mistakes. She noted that his hyperactivity manifests as constant fidgeting, difficulty remaining seated, and often interrupting others. John Miller added that David's impulsivity often leads to blurting out answers in class and struggling with turn-taking during games with peers. They both observed that these issues have been present since kindergarten but have intensified over the past year, especially with the transition to year 3. David's teachers have reported similar concerns, indicating a significant impact on his learning and classroom participation. David himself reported feeling "antsy" and finding it hard to concentrate, which makes him feel frustrated. He also mentioned worrying about tests and making friends. David's home life is generally stable, but Sarah Miller noted an increase in parental stress due to David's challenging behaviours, particularly around homework time. John Miller mentioned that David often struggles to complete homework assignments, leading to arguments and prolonged evenings. David's anxiety at home sometimes presents as difficulty falling asleep or resisting bedtime. Despite these challenges, David enjoys playing football and participates in an after-school art club, though his parents noted occasional difficulty managing his impulsivity during group activities. David is currently seeing Dr. Eleanor Vance, a paediatric psychologist, for cognitive behavioural therapy (CBT) for anxiety. He attends weekly sessions at the local community health centre, with the goal of developing coping mechanisms for anxiety and improving emotional regulation. He also has monthly follow-up appointments with Ms. Rachel Green, an occupational therapist at the school, focusing on strategies for organisational skills and attention regulation in the classroom. ROS: Negative for recent fevers, chills, or weight changes. Denies significant headaches or vision changes. No recurrent ear infections or sore throats. Reports occasional abdominal pain, typically associated with anxiety, but no vomiting or diarrhoea. No urinary symptoms. No history of seizures or significant neurological issues. Skin examination reveals mild eczema patches on inner elbows and behind knees, which are well-controlled with topical moisturisers. Birth History: Born full-term at 39 weeks via spontaneous vaginal delivery. No perinatal complications. Birth weight was 3.5 kg. Apgar scores were 9 at 1 minute and 10 at 5 minutes. Past Medical History: 1. Eczema, diagnosed at 6 months of age, managed with topical emollients. 2. History of seasonal allergies, managed with oral antihistamines as needed. 3. Mild asthma, diagnosed at age 5, well-controlled with salbutamol inhaler as needed, used rarely. Past Surgical History: 1. Tonsillectomy and adenoidectomy at age 4 due to recurrent tonsillitis and obstructive sleep apnoea. No complications. Immunisations: Up to date as per UK national schedule. Allergies: 1. Penicillin: rash (childhood). 2. Dust mites: sneezing, watery eyes. Family History: 1. Mother (Sarah Miller): History of anxiety and depression. 2. Father (John Miller): History of ADHD (diagnosed in adulthood). 3. Paternal uncle: Autism Spectrum Disorder. Social History: David lives with both parents, Sarah and John Miller, and a younger sister, Emily (age 5), in a semi-detached house. Parents are both employed full-time. The family reports a supportive home environment, though they acknowledge challenges related to David's ADHD and anxiety. David attends Sunnybrook Primary School. He has a good relationship with his sister but sometimes struggles with sharing and turn-taking. Diet: As detailed in History of Presenting Complaint. David has a balanced diet, enjoys a variety of foods, but tends to graze rather than eat structured meals when stressed. No significant feeding difficulties reported. Development: Achieved early motor milestones within normal range. Language development was slightly delayed, with first words at 18 months and full sentences by 3 years, but now age-appropriate. Social-emotional development has been impacted by his ADHD symptoms, particularly in peer interactions. Bonding with parents was reported as strong. PHYSICAL EXAM Vitals: Temperature: 36.8°C Pulse: 88 bpm Respiratory rate: 18 breaths/min Blood pressure: 102/64 mmHg Oxygen saturation: 99% on room air Growth parameters: Weight: 28 kg (50th percentile) Height: 128 cm (60th percentile) Head circumference: 52 cm (50th percentile) General: Alert, cooperative, well-nourished child. Appears younger than stated age. Mildly fidgety during examination. HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive to light. Tympanic membranes clear bilaterally. Oropharynx clear. Neck: Supple, no lymphadenopathy. Cardiovascular: Regular rate and rhythm, no murmurs. Respiratory: Clear to auscultation bilaterally, no wheezes or crackles. Abdomen: Soft, non-tender, non-distended, normoactive bowel sounds. Genitourinary: Deferred. Musculoskeletal: Full range of motion, no deformities. Neurological: Cranial nerves II-XII intact. Gross and fine motor movements appear age-appropriate. Deep tendon reflexes 2+ bilaterally. Labs: Full Blood Count: Within normal limits (1 November 2024) Thyroid Function Tests: Within normal limits (1 November 2024) Ferritin: 45 ng/mL (normal range) (1 November 2024) Diagnostic Imaging: No recent diagnostic imaging studies performed. Assessment: David Miller is an 8-year-old male with a known history of Attention Deficit Hyperactivity Disorder (combined presentation) and mild anxiety. His current presentation demonstrates ongoing significant impairment in academic and social functioning due to core ADHD symptoms and heightened anxiety. Current management with Methylphenidate and therapy is partially effective, but further adjustments may be beneficial to optimise symptom control and functional outcomes. The patient's family history of ADHD and anxiety are relevant contributing factors. Plan: 1. Continue Methylphenidate 10mg modified release daily. Monitor for efficacy and side effects; consider dose titration at next review if symptoms persist and are significantly impairing. 2. Continue weekly CBT with Dr. Eleanor Vance for anxiety. Request a progress report from Dr. Vance prior to next review. 3. Continue monthly occupational therapy with Ms. Rachel Green. Request an update on strategies implemented and progress in school. 4. Advise parents to implement a structured routine for homework and incorporate regular physical activity to help manage hyperactivity. 5. Discuss school accommodations with parents, including preferential seating and extended time for tasks, if not already in place. 6. Schedule a follow-up appointment in 3 months to reassess symptom severity, medication efficacy, and overall functional improvement. Consider a formal ADHD rating scale at follow-up. Summary: David presents with ongoing ADHD symptoms and anxiety requiring continued multidisciplinary management. The current plan aims to optimise medication effectiveness, enhance coping strategies through therapy, and support school and home environments. Close follow-up is essential to monitor progress and adjust interventions as needed to improve David's quality of life and functional outcomes.