Letter to Dr. Sarah Evans, GP
Visit Diagnosis/Symptom Complex:
1. Attention Deficit Hyperactivity Disorder (ADHD), Combined Presentation
Problem List:
1. Developmental Language Disorder
2. Anxiety Disorder, unspecified
Current Medicines:
1. Atomoxetine 10mg, capsule, once daily in the morning
Education:
Attends St. Michael's Primary School, Year 4. Requires additional support for reading and writing.
Examination:
Weight: 32 kg
Height: 135 cm
Blood pressure: 100/65 mmHg, within normal limits for age and height.
Plan:
1. Continue Atomoxetine 10mg daily. Review effectiveness and side effects in 4 weeks.
2. Recommend a referral for cognitive behavioural therapy (CBT) for anxiety management.
3. Liaise with school regarding ongoing academic and behavioural support strategies.
Outcome:
Patient and mother were receptive to the plan. Follow-up appointment scheduled for 1 December 2024 to review medication and progress. GP referral for CBT to be sent today.
Dear Colleagues,
I was pleased to review 9-year-old Oliver Smith, who was brought to my community clinic by his mother, Mrs. Emily Smith.
Oliver was referred to our service by his GP, Dr. Sarah Evans, due to ongoing concerns regarding his inattention, hyperactivity, and impulsivity, particularly in the school setting. Mrs. Smith reported that these difficulties have been present since early childhood and have significantly impacted Oliver's academic progress and social interactions. This is the first contact with our paediatric service for these specific concerns, although Oliver has previously been seen for a developmental language assessment two years ago.
Current Situation:
Mrs. Smith described Oliver as a bright and energetic child who struggles to sustain attention during tasks, often fidgets excessively, and frequently interrupts conversations. At home, he finds it difficult to follow multi-step instructions and often misplaces his belongings. His mother also noted increased irritability and occasional emotional outbursts, especially when frustrated. She is particularly concerned about his declining academic performance in reading and writing, despite additional support at school.
In-Clinic Questionnaires:
Oliver self-reported feeling restless and finding it hard to concentrate in class. He mentioned sometimes feeling overwhelmed by too many instructions and that his mind often wanders. He expressed a desire to do well in school but struggles with completing assignments on time.
Mrs. Smith clarified that Oliver's difficulties are more pronounced in structured environments like school, but also manifest at home during homework or chores. She added that he often blurts out answers before thinking and struggles with turn-taking in games with his younger sister.
Relevant background information includes a history of mild language delay identified at age 5, for which he received speech and language therapy. There is no reported history of significant trauma, but Oliver has expressed anxiety about school performance in the past.
Development:
Oliver’s early motor milestones were within the typical range. Speech development was slightly delayed, with first words at 18 months and full sentences by 3 years, necessitating speech and language therapy which has since been discharged. He continues to have some difficulties with complex sentence structures and phonological awareness.
Sleep:
Oliver typically falls asleep around 9 PM and wakes at 7 AM. Mrs. Smith reported that he sometimes has difficulty settling down at night due to an active mind, occasionally requiring a guided meditation app. No medications are currently used to support sleep.
Past Medical History and Background:
Born full-term via normal vaginal delivery, no perinatal complications. Past medical history is largely unremarkable aside from recurrent ear infections in early childhood, resolving by age 5. No known allergies. Up-to-date on all childhood vaccinations.
Family History:
Oliver lives with his mother, father, and younger sister. His maternal uncle was diagnosed with ADHD in adulthood. There is a family history of anxiety on his mother's side. No other significant medical or mental health history reported.
ADHD Evaluation:
Information from Mrs. Emily Smith, mother in September 2024
Strengths:
Mrs. Smith described Oliver as creative, imaginative, and highly empathetic. He is very kind to animals and enjoys drawing and building with Lego. He has a good sense of humour and is generally well-liked by his peers.
Challenges:
Challenges highlighted include difficulty with organisation, forgetfulness, impulsivity leading to interruptions, and struggles with task completion. He often requires significant prompting to stay on task.
Information from the School in July 2024 and September 2024
Strengths:
The school reported Oliver as a cheerful and enthusiastic learner who participates actively in discussions when engaged. He shows strong visual-spatial skills in art and design technology.
Challenges:
School reports indicate difficulties with maintaining focus in class, particularly during independent work. He often rushes through tasks, leading to careless errors, and struggles to follow multi-step instructions. Teachers have noted frequent fidgeting and difficulty remaining seated.
Information from School – Received October 2024
Strengths:
Recent feedback from his Year 4 teacher highlighted Oliver's improved effort in group projects and his willingness to help classmates. He continues to excel in creative subjects.
Challenges:
Recent challenges include difficulties with planning and organising his school bag and materials, leading to missed homework. He continues to struggle with managing distractions in the classroom and occasional emotional outbursts when corrected or frustrated with academic tasks. Socially, he sometimes struggles with turn-taking during group activities.
Conner's parent/teacher and self-report questionnaires gather information regarding a range of behaviours and symptoms. The scores indicate whether the observed symptoms are disproportionate to those expected for a child of the same age. T-scores > 70 for attention and hyperactivity/impulsivity in all settings indicate that the symptoms are significant.
Parents' Rating T Scores – October 2024
Inattention / Executive Dysfunction: 78
Hyperactivity: 75
Impulsivity: 72
Emotional Dysregulation: 68
School work: 70
Peer interactions: 65
Family Interactions: 69
Teachers' Rating T Scores – October 2024
Inattention / Executive Dysfunction: 79
Hyperactivity: 76
Impulsivity: 73
Emotional Dysregulation: 65
School work: 72
Peer interactions: 67
Self-Reported T Scores:
Inattention / Executive Dysfunction: 68
Hyperactivity: 62
Impulsivity: 65
Emotional Dysregulation: 70
School work: 69
Peer interactions: 60
Family Interactions: 63
QB Test – October 2024
Oliver completed the QB test demonstrating challenges with sustained attention and impulse control. His performance was significantly below the age-matched norm, particularly for vigilance and motor control.
The scores were as follows:
Activity level: 1.8 (Increased motor activity, consistent with hyperactivity)
Attention: 0.9 (Significantly reduced attention, indicating difficulties with focus)
Impulsivity: 1.5 (Increased impulsive responses, suggesting poor inhibition)
On Examination:
Oliver presented as an alert and engaging child. He was initially restless in his seat, frequently shifting position and fiddling with his clothes. He made good eye contact during direct conversation but was easily distracted by sounds and movements in the room. Speech was fluent but he occasionally interrupted. Gross and fine motor skills appeared age-appropriate. No dysmorphic features or focal neurological deficits were noted.
Conclusion and Plan:
Based on the comprehensive history from his mother, school reports, and the objective findings from the Conner's questionnaires and QB test, Oliver meets the diagnostic criteria for Attention Deficit Hyperactivity Disorder, Combined Presentation. The difficulties are pervasive across multiple settings (home and school) and have significantly impacted his academic and social functioning for over six months. Given the severity of symptoms and the impact on his daily life, a trial of Atomoxetine 10mg daily was initiated after discussing the benefits and potential side effects with Mrs. Smith. We also discussed the importance of ongoing behavioural strategies at home and school. A referral for CBT for anxiety management will also be made. Follow-up is arranged in 4 weeks to review the medication's effectiveness and tolerability. We will also collaborate with the school to ensure appropriate educational support is in place.
This letter summarises today's clinic appointment. It was created using voice recognition software. If you have any inaccuracies or questions, please contact me at 0123456789.
Letter to [Recipients of this letter] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Visit Diagnosis/Symptom Complex:
1. [Primary diagnosis or symptom complex for this visit] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a numbered list. Do not invent or infer a diagnosis.)
Problem List:
1. [Chronic problems or diagnoses] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a numbered list. Do not invent or infer a diagnosis.)
Current Medicines:
1. [Current medications including name, form, dosage and frequency or instructions for use] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a numbered list.)
Education:
[Educational setting and relevant details] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Examination:
Weight: [Patient weight] kg (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Height: [Patient height] cm (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Blood pressure: [Blood pressure reading and interpretation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Plan:
1. [Document the discussed treatment plan and recommendations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a numbered list.)
Outcome:
[Outcome of the appointment and follow-up arrangements] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
”Dear Colleagues,”
I was pleased to review [Patient age and name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.), who was brought to my community clinic by [Relationship of accompanying person] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.).
[History of referral and any prior contact with the service] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in narrative paragraphs.)
Current Situation:
[Current presenting situation and concerns as reported by the accompanying person] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in narrative paragraphs.)
In-Clinic Questionnaires:
[Patient's self-reported experiences, perceptions and coping mechanisms discussed during the consultation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in narrative paragraphs.)
[Accompanying person's additional observations and clarifications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in narrative paragraphs.)
[Relevant background information including any history of trauma and its relationship to current symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in narrative paragraphs.)
Development:
[Summary of developmental milestones including motor and speech development] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in narrative paragraphs.)
Sleep:
[Description of the patient's sleep patterns and any medications used to support sleep] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in narrative paragraphs.)
Past Medical History and Background:
[Summary of birth history, past medical conditions, allergies and vaccination status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in narrative paragraphs.)
Family History:
[Summary of family structure and relevant family medical or mental health history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in narrative paragraphs.)
ADHD Evaluation:
Information from [Source of information] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) in [Month and year of information] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Strengths:
[Summary of the patient's strengths as reported by the source] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit this subheading and content entirely. Write in narrative paragraphs.)
Challenges:
[Summary of the patient's challenges as reported by the source] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit this subheading and content entirely. Write in narrative paragraphs.)
Information from the School in [Month and year] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) and [Month and year] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Strengths:
[Summary of the patient's strengths in the school setting] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit this subheading and content entirely. Write in narrative paragraphs.)
Challenges:
[Summary of the patient's challenges in the school setting including academic performance and support strategies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit this subheading and content entirely. Write in narrative paragraphs.)
Information from School – Received [Month and year] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Strengths:
[Summary of recent strengths in the school setting] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit this subheading and content entirely. Write in narrative paragraphs.)
Challenges:
[Summary of recent challenges in the school setting including academic performance, social interactions and emotional regulation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit this subheading and content entirely. Write in narrative paragraphs.)
(Only include the following paragraph if Conner's questionnaires were used and mentioned in transcript, contextual notes or clinical note, else omit this paragraph entirely.)
"Conner's parent/teacher and self-report questionnaires gather information regarding a range of behaviours and symptoms. The scores indicate whether the observed symptoms are disproportionate to those expected for a child of the same age. T-scores > 70 for attention and hyperactivity/impulsivity in all settings indicate that the symptoms are significant."
Parents' Rating T Scores – [Month and year of parent rating] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Inattention / Executive Dysfunction: [Score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Hyperactivity: [Score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Impulsivity: [Score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Emotional Dysregulation: [Score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
School work: [Score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Peer interactions: [Score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Family Interactions: [Score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Teachers' Rating T Scores – [Month and year of teacher rating] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Inattention / Executive Dysfunction: [Score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Hyperactivity: [Score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Impulsivity: [Score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Emotional Dysregulation: [Score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
School work: [Score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Peer interactions: [Score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Self-Reported T Scores:
Inattention / Executive Dysfunction: [Score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else keep the heading but leave the placeholder blank.)
Hyperactivity: [Score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else keep the heading but leave the placeholder blank.)
Impulsivity: [Score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else keep the heading but leave the placeholder blank.)
Emotional Dysregulation: [Score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else keep the heading but leave the placeholder blank.)
School work: [Score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else keep the heading but leave the placeholder blank.)
Peer interactions: [Score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else keep the heading but leave the placeholder blank.)
Family Interactions: [Score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else keep the heading but leave the placeholder blank.)
QB Test – [Month and year of QB test] (Only include if QB test was performed and mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Summary of the QB test context and findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
The scores were as follows:
Activity level: [Score and interpretation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Attention: [Score and interpretation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Impulsivity: [Score and interpretation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
On Examination:
[Physical and behavioural examination findings observed during the consultation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in narrative paragraphs.)
Conclusion and Plan:
[Clinical reasoning, diagnostic conclusions and rationale for the plan including discussion of strategies and follow-up] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in narrative paragraphs.)
"This letter summarises today's clinic appointment. It was created using voice recognition software. If you have any inaccuracies or questions, please contact me at [Clinician contact details]." (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
