ADHD Basic Template

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.