Office Visit Note
Reason: Office Visit ElationNoteColOne: HPI: Hpi: 1. ADHD [F90.9] * He is taking guanfacine 1.5 mg twice daily and loratadine. * He feels the medication is not working well. * Per mother, he has been sleeping a lot; this was also noted about 6 months ago. * He has been sitting unusually calmly today. * School is starting soon, and there is concern about maintaining steadier symptom control. * He is transitioning from a dual-language track to his community school for 6th grade, which is expected to be an adjustment socially and academically. Hpi: 2. Musculoskeletal * He reports pain at one area after another child tripped him 2 years ago. * He plays soccer and basketball. * He has bowel movements daily. Hpi: 3. Hygiene/diet * He showers most nights but sometimes skips about once weekly. * He uses deodorant/antiperspirant, but not daily. * Diet is being adjusted toward healthier snacks after camps/activities. * He likes salad, does not like French fries, and will drink smoothies with protein powder at times. ElationNoteColOne: Reconciled Medications: Med: * Guanfacine 1.5 mg PO BID Med: * Loratadine ElationNoteColOne: Social History: Social: * Entering 6th grade. Social: * Changing schools from dual-language program to community school. Social: * Participates in soccer and basketball. ElationNoteColOne: Habits: Habits: * Showers nearly nightly; may skip approximately once per week. Habits: * Does not use deodorant daily. Habits: * Working on healthier food choices and snack habits. ElationNoteColTwo: Data: Data: * Reviewed current guanfacine regimen as 1.5 mg twice daily. Data: * Discussed pharmacy concern that tablets are extended release and splitting is suboptimal because it alters release characteristics, though it has been used to achieve current dosing. Data: * Discussed that recent growth may warrant dose escalation. Data: * Reviewed immunization timing: influenza vaccine deferred as it is early in the season; no FluMist available. Data: * Reviewed vaccine schedule: if vaccination is delayed until after age 15, a 3-dose series would be needed. Data: * Sports physical form for school discussed; standard Minnesota sports clearance form to be completed. ElationNoteColTwo: Vitals: Data: - BMI: 20.0 - Height (in): 63.5 - Weight (lbs): 115 ElationNoteColTwo: PE: PE: - General: Pubertal development advanced for age compared with peers. - HENT: Head/hair exam performed. - Abdom: No concerns elicited regarding bowel habits; stools daily. - GU: External genital exam performed. - MSS: Hamstrings tight bilaterally with marked limitation in toe-touch flexibility. Mild tenderness/tension noted at lower extremities near major muscle attachment sites, consistent with growth-related tightness/inflammation. No acute sports-limiting abnormality otherwise discussed. - NS: Calm, seated behavior during visit. - Psych: Interactive and appropriate. ElationNoteColTwo: Assessment & Plan: Assessplan: 1. ADHD [F90.9] Assessplan: 2. Sleepiness/fatigue, likely related to growth/puberty [R53.83] Assessplan: 3. Muscle tightness/poor flexibility with sports participation [M62.89] Assessplan: 4. Pubertal development [Z00.3] Assessplan: 5. Dietary counseling and surveillance [Z71.3] Assessplan: 6. Encounter for immunization counseling [Z71.85] Assessplan: 7. Encounter for examination for participation in sport [Z02.5] ElationNoteColTwo: Follow Up: Followup: Update me in 1-2 weeks after increasing guanfacine. Follow up as needed for medication adjustment and school/sports forms.