Referral note- behaviour/mental health

Chief Complaint

Patient Referral Report

tags

specialty

Pediatrics

Template

Thank you for your referral. (This report is composed by Dr. Merchant, and it is generated by voice recognition software. Transcription errors may occur. If one has any concern regarding accuracy, we will be pleased to clarify) Reason for Referral: [name] is a [age] year old [gender] who has been referred for assessment and management of behaviour. History of Present Illness: [pronoun] attended todays appointment with [pronoun] [parent]. Parent reports that its quite different at home then school. [[pronoun] is very quiet at school.] [[pronoun] wont talk to the teacher or friends.] [[pronoun] wont respond to kids if they say Hi]. [At home [pronoun] is active, energetic.] [[pronoun] brings emotion home.] [pronoun] will over react. [pronoun] said there is a real me and a fake me. [pronoun] has a close friend [name]. [pronoun] says [pronoun] has known [pronoun] for [number] years and [pronoun] wears glasses. [pronoun] is currently in grade [number]. Parents arrange play dates with class mates. [pronoun] has a [age] year old brother and [pronoun] follows [pronoun] and [pronoun] brothers friends. Parents are concerned that [pronoun] shuts [pronoun]self off when kids reach out to [pronoun]. [pronoun] doesn't express [pronoun] needs. [pronoun] has a lot of anger which is expressed at home. Parents have noted a worsening of behaviour in Grade [number]. They also noted that [pronoun] is further closing [pronoun]self off from friends. [pronoun] is working with a behaviour therapist for [duration], every week. [pronoun] is at class level from the academic perspective.[pronoun] is very dependent on family for self care and home work though [pronoun] can do these functions. [pronoun] is afraid of dark so has difficulty sleeping at night. [pronoun] parents sleep in [pronoun] room otherwise [pronoun] wont sleep. [pronoun] has difficulty falling asleep. [pronoun] eats well. [pronoun] holds stool and wets bed sometime. FM skills slowly improving. [pronoun] cant sit still. [pronoun] follows instructions .No complaint from the teacher. [pronoun] is impatient and impulsive. [pronoun] is in hockey,swimming and basketball. [pronoun] plays piano, skating and skiing. Review of System; CNS: Unremarkable RESP: Unremarkable CVS: Unremarkable GI: Unremarkable GU: Unremarkable DERM: Unremarkable MSK: Unremarkable Immunization: up to date Allergies: NKDA Active Medications: None Recorded Development: Appropriate for age Birth History: Pregnancy: unremarkable, term, SVD, BW [weight] lbs Delivery: uneventful Post Natal: insignificant Past Medical History: unremarkable Family History: [pronoun] lives at home with parents, paternal grandparents live across street and [age] year old brother, [name]. [pronoun] was diagnosed at age [age]. [pronoun] is verbal and grade [number]. Mom is [age], healthy, University,Risk analyst full time Dad is [age], HT and high cholesterol and on medication. Dad had anxiety and was on medication but better now. Dad feels [pronoun] may be on the spectrum, [pronoun] mom too. Social History: unremarkable Physical Examination: WT: [weight] [number] %ile HT: [height] [number] %ile HC: %ile BP: [number] HR: [number] TEMP: HEENT: Child looks well, no gross dysmorphic features Eyes: PEARL, Red reflex present, Clear conjunctiva Ears: Clear, intact TM bilaterally Throat & Palate: Normal LNs: Insignificant Chest: Air entry equal bilaterally, no adventitious sounds heard. CVS: Quiet pericordium: Normal S1 & S2, no murmur heard PPP + CR <2 seconds Abdomen: Soft, no masses, no organomegaly, no tenderness, normal BS GU: Appropriate for sex & age Tanner MSK: unremarkable Derm: unremarkable CNS: Grossly normal Impression & Plan: [name] is a [age]-year-old [gender] who suffers from anxiety and possibly mild selective mutism. [pronoun] symptoms present as rigidity, temper tantrums at home and sleep issues. Parents have started behaviour therapy for the past [duration]. They keep the lights on and have [pronoun] do breathing exercises to help with sleep.. [pronoun] does physical activity such as hockey and swimming. I recommended adding natural supplements like [supplement] [dosage] daily and [supplement] [dosage] for a [duration] period to reset [pronoun] sleep cycle. I will continue to monitor for ADHD. I would like to follow-up in [duration]. Thank you for involving me in the care of your patient. Should you have any questions, please do not hesitate to contact me.