CHIEF COMPLAINT: Follow up ADHD.
HISTORY OF PRESENT ILLNESS: The patient is here today to follow up on attention deficit hyperactivity disorder. One month ago, she saw her primary care physician and was prescribed 20 mg per day amphetamine/dextroamphetamine ER. Since that time, she says she has been tolerating the medication well without chest pain, palpitations, anorexia, weight loss, or insomnia. She does complain of a dry mouth, which she relieves by drinking water throughout the day. The patient says that since beginning the medication, she noticed that she has been more alert, particularly with driving. However, she is wondering if a somewhat higher dose might give her additional benefit and help her more with her school work, as she still is having a difficult time concentrating on that. The patient continues to take Prozac 40 mg daily the week of her period only.
REVIEW OF SYSTEMS: No weight loss. No depression or anxiety. No chest pain or palpitations. Positive for dry mouth.
PHYSICAL EXAMINATION: In general, the patient is in no acute distress. Blood pressure is 92/62, pulse 68, respiratory rate 20. In general, this is a well-developed, well-nourished appearing woman, in no acute distress. Mental status exam is intact without overt depression or anxiety.
ASSESSMENT: Attention deficit hyperactivity disorder, improved on amphetamine and dextroamphetamine ER 20 mg.
PLAN: We will give the patient a trial of amphetamine/dextroamphetamine ER 25 mg, and she will see if this increases the benefit she is getting from the medication. She is scheduled for a physical and she will follow up on this at that time. Encouraged her to call us if she develops any new signs and symptoms or if intolerable side effects or dry mouth on the 25 mg dosage occurs.
This assessment started at 11:30 a.m. and ended at 11:45 a.m.
HISTORY: The patient is an (XX)-year-old boy who will be in the (XX)th grade at (XX) Elementary. He carries a diagnosis of ADHD, combined type, with ODD. Currently, he is on Metadate CD 20 mg q.a.m. The patient reported on time for this assessment. He was accompanied by his mother and resource coordinator. The patient is doing well since he was switched to Metadate CD. No acute management problems reported. No symptoms suggestive of psychosis or mania reported. He is compliant with his medications.
MENTAL STATUS EXAMINATION: No clinically significant features were noted. He describes his mood as fine. His affect is bright and full range. He does not appear to be responding to any abnormal perceptions or delusions. His judgment is age appropriate.
DIAGNOSES:
1. Attention deficit hyperactivity disorder, combined type.
2. Oppositional defiant disorder.
RECOMMENDATIONS:
1. The patient does not pose any imminent danger of harming himself or others; therefore, his outpatient status should be maintained.
2. Metadate CD 20 mg p.o. q.a.m. should continue as he is not reported to have any major side effects associated with it.
3. The patient should continue to follow up with his RN at regular intervals.
4. The patient should return for reassessment.
