Well-Child Visit (13-17 yr)

Subjective:
Chief Complaint:
Follow-up ADHD management and medication effectiveness

Interval History:
Here as established patient with parent as historian. Lucas has been on 40 milligrams of medication for attention-deficit/hyperactivity disorder. He reports improvement in focus, particularly in science classes, and feels more confident, especially during physical education and basketball. Parent notes that Lucas has been more tired recently and has some difficulty with sleep onset despite going to bed at 9:30 PM. Appetite is described as reduced, with limited intake in the morning and incomplete lunch consumption. Dietary advice regarding limiting sugary drinks and considering no-sugar sparkling water was discussed.

BF4 - Nutrition:
Daily fruits and vegetables: No information available
Iron: No information available
Calcium: No information available
Body image: No concerns
Attempting to gain or lose weight: No
No mention of significant weight loss or gain. No mention of soda consumption being excessive.

BF4 - Dental Home:
Dental Home: No information available
Regular visits: No information available
Brushing twice daily: No information available

BF4 - Sleep:
Sleep concerns: Yes. Lucas reports difficulty with sleep onset despite going to bed at 9:30 PM. No mention of other sleep disturbances apart from difficulty falling asleep.

BF4 - Physical Activity:
Exercise (60 min/d): Yes
Activities: Basketball, physical education
Screen time: No information available
No mention of dislike for PE or physical activity.

BF4 - School:
Grade: No information available
IEP/504/behavior plan: No information available
Performance: Lucas reports improved focus in class, especially in science, but continues to find mathematics challenging due to lack of interest. No mention of difficulty focusing in science.

BF4 - Employment:
Employment: None

BF4 - Development:
Forms caring, supportive relationships: No information available
Engages in community: No information available
Engages in wellness behaviors: Yes
Demonstrates competencies: Yes
Exhibits compassion and empathy: No information available
Exhibits resilience: Yes
Uses independent decision-making skills: Yes
Displays self-confidence and well-being: Yes

The Review of Systems:
General: Lucas reported increased fatigue and difficulty initiating sleep despite going to bed at 21:30 hours. 
Endocrine: Parent reported decreased appetite, with Lucas eating a small amount in the morning and not always finishing his lunch. 
Psychological: Lucas described feeling somewhat more confident, particularly when participating in basketball.

Adolescent History:
Lucas is an adolescent male who is physically active and enjoys participating in basketball. He is performing well academically in science, though he finds mathematics less engaging. He has demonstrated improvement in focus and impulse control since initiation of pharmacologic therapy for attention-deficit/hyperactivity disorder. He experiences increased fatigue and difficulty with sleep onset, as well as a reduced appetite. There is no mention of confidence issues outside of school or sports.

Objective:
Physical Exam:
GENERAL: Growth parameters show height in the 85th percentile and weight in the average range. Appearance is active and well-nourished.
HEAD: No information available
EYES: No information available
EARS: No information available
NOSE: No information available
MOUTH: No information available
OROPHARYNX: No information available
NECK: No information available
HEART: No information available
CHEST: No information available
LUNGS: No information available
ABDOMEN: No information available
SPINE: No information available
EXTREMITIES: No information available
NEURO: No information available
GENITALIA: No information available
SKIN: No information available
PSYCH: No information available

Assessment and Plan:
- Attention-Deficit/Hyperactivity Disorder, Combined Presentation (F90.2): Lucas has demonstrated improvement in attention and impulse control with current pharmacologic management at a dose of 40 milligrams. He continues to experience difficulty with sleep initiation and reduced appetite, which are recognized side effects of his medication. He reports increased confidence during athletic activities and improved academic focus, particularly in science. 
Plan:
• Continue current medication regimen at 40 milligrams.
• Monitor for ongoing sleep disturbances and appetite suppression.
• Advised use of a visual checklist to support morning routine independence.
• Recommended limiting intake of sugar-sweetened beverages and substituting with non-sugar sparkling water to support sleep hygiene and focus.
• Encouraged continued participation in physical activity to support confidence and overall well-being.
• Scheduled follow-up visit in the summer to reassess sleep, appetite, and academic performance.
• Provided education regarding the importance of adequate nutrition and sleep, and discussed the potential side effects of medication, including insomnia and appetite suppression.