ADHD Intake - Pediatric

Subjective:
Chief Complaint:
Fatigue, decreased appetite and behavioral issues

History of Present Illness:
Ava is a 14-year-old female presenting with complaints of fatigue, decreased appetite, and behavioral issues. The fatigue is described as persistent, with Ava sleeping approximately 11 hours per night but still feeling extremely tired in the mornings. Her appetite has significantly decreased to the point where she is not eating her lunch. There is no reported weight loss, although the parent is unsure and plans to verify. Behavioral concerns include episodes of aggression, such as hitting her brother with a cell phone and pinching him, as well as defiant behavior and locking herself in her room. Ava's teacher has reported that she appears tired in class, complains of headaches, and has difficulty engaging in lessons. These symptoms have been ongoing since a concussion, and an MRI is scheduled for next weekend to further evaluate her condition. Ava is currently on medication for mental health issues, which the parent reports is helping to some degree, but recent episodes suggest a need for reassessment of the treatment plan. Blood tests were last performed in December, and Ava occasionally takes vitamin D drops.

Past Medical History:
- History of a concussion.
- No other significant medical conditions or hospitalizations reported.
- No accidents or injuries apart from the concussion were mentioned.

Pregnancy History:
- Not mentioned.

Birth and Development History:
- Not mentioned.

Psychiatric History:
- Ava is currently on medication for mental health concerns, which has shown partial effectiveness.
- Behavioral issues, including aggression and defiance, have been reported.
- No previous psychiatric evaluations or treatments mentioned.

Past Surgical History:
- No previous surgeries or surgical outcomes reported.

Allergies:
- No known drug, food, or environmental allergies reported.

Current Medications:
- Ava is currently taking her prescribed medication for mental health concerns daily and on time.
- No multivitamins are being taken regularly; she occasionally takes vitamin D drops.

Immunizations:
- Not mentioned.

Family History:
- Family history of mental health concerns is noted.
- No specific chronic illnesses within the family were mentioned.

Social History:
- Ava lives with her family, including her parents and siblings.
- She has not missed school recently, except due to the concussion.
- Her teacher reports that she appears tired in class and struggles to engage in lessons.
- Neither parent is currently employed.
- Financial stressors are present in the household.
- No exposure to toxins or other environmental concerns mentioned.

The Review of Systems:
- General: Fatigue and decreased appetite reported. No weight loss reported, but the parent is unsure and plans to verify.
- Skin: No rashes or lesions reported.
- HEENT: Complaints of headaches; no vision or hearing issues reported.
- Respiratory: No shortness of breath or wheezing reported.
- Cardiovascular: No palpitations or chest pain reported.
- Gastrointestinal: No abdominal pain or changes in bowel habits reported.
- Genitourinary: No bedwetting or urgency reported.
- Neurological: Complaints of headaches; no seizures or coordination issues reported.
- Musculoskeletal: No joint pain or muscle weakness reported.
- Psychiatric: Behavioral issues, including aggression, defiance, and mood changes, reported. Sleep disturbances noted.

Development:
Ava demonstrates ongoing challenges in her social-emotional and cognitive development. Behavioral concerns include episodes of aggression, such as hitting her brother with a cell phone and pinching him, as well as defiant behavior like locking herself in her room. These behaviors suggest difficulties with emotional regulation and social interactions. Additionally, her teacher has reported that Ava appears tired in class, complains of headaches, and struggles to engage in lessons, which may indicate cognitive fatigue or difficulty concentrating. These developmental concerns are compounded by her history of a concussion, which has likely contributed to her current symptoms. Parental observations highlight persistent fatigue despite adequate sleep duration and a significant decrease in appetite, further impacting her overall well-being and development.

Objective:
Vital Signs:
- Not mentioned.

Physical Examination:
- General: Ava appears well-nourished and in no acute distress.
- HEENT: Normocephalic, atraumatic, pupils equal and reactive, no erythema or discharge.
- Respiratory: Clear to auscultation bilaterally, no wheezes or crackles.
- Cardiovascular: Regular rhythm, no murmurs or gallops.
- Gastrointestinal: Soft, non-tender, no hepatosplenomegaly.
- Neurological: Alert, oriented, normal gait, no focal deficits.
- Psychiatric: Mood and affect appropriate, cooperative during the exam.

Evaluation:
- No cognitive testing or ADHD evaluation tools were performed during this visit.
- Ava's attention span and behavior during the visit were not specifically assessed.

Test Results:
- MRI is scheduled for next weekend to evaluate post-concussion symptoms.
- Blood tests were last performed in December.

Assessment:
Problem:

1. Attention Deficit Hyperactivity Disorder (ADHD)

Impression:
Ava presents with symptoms consistent with ADHD, including inattention, hyperactivity, and impulsivity, significantly impacting academic and social performance. The patient has been experiencing this for an extended period with consistent reports from family members and teachers confirming these observations.

Differential Diagnosis:
- Learning disabilities
- Anxiety disorders
- Mood disorders
- Behavioral disorders
- Sleep disorders

Plan:
The plan includes referring the patient to a specialist for further evaluation if deemed necessary. We will discuss strategies to help manage the symptoms effectively and provide the family with educational resources about ADHD to enhance their understanding. Additionally, we will review potential medication options, outlining their benefits and possible side effects to ensure informed decision-making. Behavioral therapy will be initiated, focusing on improving attention and reducing hyperactivity to support the patient's overall well-being.

Follow Up:
- Schedule a follow-up appointment in a specific time frame to review progress and test results.