Well Child Visit (2 week)

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

Accompanied By:
Parent (Relationship not specified)

Concerns and Questions:
Follow-up of attention-deficit/hyperactivity disorder management and assessment of medication effectiveness.

Interval History:
Lucas is an established patient presenting for follow-up of attention-deficit/hyperactivity disorder management. There is reported improvement in focus, particularly in science, with ongoing difficulty focusing in mathematics. No mention of difficulty focusing in science.

Nutrition:
Lucas consumes a small amount of food in the morning and brings lunch to school but does not always finish it. There is a recommendation to limit sugary drinks and consider no-sugar sparkling water. No mention of significant weight loss or gain.

Elimination:
No mention of elimination issues.

Sleep:
Lucas reports difficulty falling asleep despite going to bed by 9:30 PM. No mention of other sleep disturbances beyond difficulty falling asleep.

Behavior:
Lucas demonstrates improved focus and confidence, especially during physical education and basketball. No mention of difficulty with physical activity or sports. No mention of behavioral issues outside of school.

Development:
Lucas demonstrates appropriate physical growth, with height in the 85th percentile and weight within the average range for age and sex. There are no parental concerns regarding gross or fine motor skills, language, or cognitive development at this time. Lucas is actively engaged in physical activities, particularly basketball, indicating age-appropriate social and emotional development. He is able to participate in school and extracurricular activities, with improved focus and confidence noted, especially during sports. No mention of developmental delays.

Objective:
Vitals:
Height is at the 85th percentile. Weight is at the average percentile. No mention of abnormal vitals.

Assessment and Plan:
Diagnoses:
1. Attention-deficit/hyperactivity disorder (F90.9)
2. Insomnia due to medication side effect (F51.09)
3. Decreased appetite secondary to medication (R63.5)

- Attention-Deficit Hyperactivity Disorder, Combined Presentation (F90.2): Lucas has exhibited improvement in attention and impulse control since initiation of pharmacotherapy, with particular benefit noted in science classes. Some residual difficulty with attention persists in mathematics, which Lucas finds less engaging. He reports increased fatigue and difficulty initiating sleep, which are recognized side effects of his current stimulant medication regimen. Appetite is mildly decreased, with reduced intake at breakfast and incomplete lunch consumption. Confidence and focus are enhanced during physical activity, particularly basketball.
Plan:
• Continue current stimulant medication at 40 mg daily, as therapeutic benefit is observed and symptoms are generally well controlled.
• Monitor for ongoing side effects, including sleep disturbance and appetite suppression; parents and patient advised to observe for any worsening of these symptoms.
• Recommended dietary modifications to support adequate caloric intake, particularly in the morning and at lunch, and advised limiting sugary beverages in favor of no-sugar sparkling water to support sleep hygiene and attention.
• Encouraged use of a visual checklist to promote independence and organization in morning routines.
• Reinforced the importance of regular physical activity for confidence and focus.
• Scheduled follow-up visit in the summer to reassess medication efficacy, sleep quality, appetite, and academic performance.
• Provided education regarding the potential side effects of stimulant medication, including insomnia and appetite suppression, and discussed strategies to mitigate these effects.
Dr. Carter
Regional Medical Center