Chief Complaint

“My son has trouble focusing and sitting still while completing his afternoon homework.”

HPI

David Handlon is a 10-year-old boy who returns for a routine visit to his psychiatrist with his mother. He was diagnosed 2 years ago with ADHD and is currently being treated with Adderall XR 20 mg every morning. His mother states that during the last parent–teacher meeting, his teacher indicated that David’s behavior is well controlled during the day. Despite David’s good behavior during the day, his mother reports difficulty getting David to complete any afternoon tasks or assignments after school. David’s rules include no playtime activities until he has completed his afternoon homework assignments. Instead of focusing on homework, David insists on playing Guitar Hero® in his room, and he sometimes carelessly throws his guitar. David has also exhibited impulsive and reckless behavior when interacting with his younger 8-year-old brother. Initially David’s mother thought the medication was working. However, within the past year, David’s afternoon antics have progressively gotten worse. MrsHandlon is afraid that uncontrolled afternoon antics will have serious repercussions on David’s daytime behavior and grades. She questions, “What are my options?”

PMH

Asthma × 3 years

ADHD × 2 years

Tonsillectomy (1 year ago)

Broken wrist at age 8 (fell from tree)

Vaccinations up to date

FH

Both father and uncle have a history of hyperactivity and are currently receiving treatment as adults.

SH

Lives with both parents and younger brother in the suburbs

Meds

Adderall XR 20 mg daily (given every morning at 7:00 AM)

Albuterol inhaler two puffs Q 4–6 H PRN shortness of breath

Montelukast 5 mg PO daily

All

NKDA

ROS

Physical assessment was difficult to assess for David as he could not sit still for more than 30 seconds and was jumping off of the exam table. Asthma symptoms appear controlled with PRN inhaler use at bedtime only and daily montelukast.

PE

Gen

Well-nourished, healthy-appearing male child, normal physical development

VS

BP 110/72 mm Hg, P 82 bpm, RR 25, T 37.5°C; Wt 50 kg, Ht 5′2″

Skin

No signs of rash, skin irritation, or bruising noted. Scar noticed on left wrist from where he fell from tree. Minor cuts on knees from frequent falls on school playground.

HEENT

Unable to assess

Neck/Lymph Nodes

Unable to assess

Lungs/Thorax

No rales, rhonchi, or wheezing

CV

RRR

Abd

Deferred

Genit/Rect

Deferred

MS/Ext

Unable to assess

Neuro

A&O × 3; no underlying tics noted

Labs

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Na 138 mEq/L

K 3.8 mEq/L

Cl 106 mEq/L

CO2 23 mEq/L

BUN 18 mg/dL

SCr 0.8 mg/dL

Glu 110 mg/dL

Hgb 14 g/dL

Hct 44.5%

RBC 4.6 × 106/mm3

Plt 278 × 103/mm3

MCV 85 μm3

MCHC 33 g/dL

 

WBC 9 × 103/mm3

Neutros 66%

Bands 2%

Eos 3%

Lymphs 24%

Monos 5%

 

Mag 1.8 mg/dL

Serum iron 95 mcg/dL

TSH 3.6 mIU/L

 

 

 

 

ECG

NSR; changes not clinically significant

Assessment

  1. ADHD
  2. Mild-persistent asthma, well controlled with PRN albuteroland daily montelukast

 

 

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