Office Visit Note
Reason: Office Visit ElationNoteColOne: HPI: Hpi: 1. Attention/focus * He is taking methylphenidate 10 mg daily. * He does not notice much benefit and feels little difference on days he misses it. * Parent reports diminished benefit by the end of the school day last year, particularly during back-to-back math and science classes. Hpi: 2. Anxiety * He is taking sertraline 50 mg daily. * Parent reports ongoing significant anxiety. * He dislikes the sertraline liquid due to unpleasant taste. * He has not really tried swallowing pills/capsules. Hpi: 3. Immunization anxiety * He was very anxious about receiving his vaccine today. ElationNoteColOne: Reconciled Medications: Med: * Sertraline oral solution 20 mg/mL, 2.5 mL (50 mg) by mouth daily Med: * Methylphenidate oral solution 10 mg by mouth daily ElationNoteColOne: Past Medical History: Past: * Anxiety Past: * Attention/focus disorder treated with methylphenidate ElationNoteColOne: Social History: Social: * Lives in Edina. Social: * Attends school in St. Louis Park. Social: * Participates in Scouts. Social: * Enjoys playing Roblox on an iPad with friends. ElationNoteColOne: Habits: Habits: * No guns in the home. ElationNoteColTwo: Vitals: Data: - BMI: 19.1 - Height (in): 65.5 - Weight (lbs): 116.6 ElationNoteColTwo: PE: PE: - General: Well appearing. - Abdom: Soft, non-tender. - GU: External genitalia normal; penis/scrotum without concerning abnormality on brief visual inspection. - MSS: No scoliosis on forward bend exam. - Psych: Anxious during vaccination; cooperative with support. ElationNoteColTwo: Assessment & Plan: Assessplan: 1. Encounter for routine child health examination without abnormal findings [Z00.129] Assessplan: 2. Anxiety disorder, unspecified [F41.9] Assessplan: 3. Attention-deficit hyperactivity disorder, unspecified [F90.9] Assessplan: 4. Encounter for immunization [Z23] ElationNoteColTwo: Procedures: Procedure: * HPV vaccine administered ElationNoteColTwo: Follow Up: Followup: Message me in 1-2 weeks to reassess response to sertraline increase and decide whether to increase further to 3.5 mL or 4 mL. Medications to be sent to Southdale pharmacy.