Pediatric primary care

Aiden is a 13-year-old white male seen in pediatric primary care for concerns regarding behavior. Mom states she “doesn’t know what to do anymore”. Aiden is failing all of his classes with the exception of gym and music. Aiden does well on test scores but does not turn in homework, even after he has completed it. Mom created a binder for him to organize all of his work in, and he has an assignment notebook where he is supposed to write down his assignments. He doesn’t often use the notebook and uses the binder properly about 50% of the time. Aiden is in 7th grade and at risk of not being able to stay in his school next year for 8th grade. Aiden is a very 13-year-old, and her mom says his teachers feel that way as well. Aiden has stayed on the same low dose of Focalin XR 10mg for 4 years, and one low dose, short-acting Adderall 5mg for homework in the evenings. Aiden expresses an increase in anxiety. Mom states that his parents separated 2 years ago, but are now in the process of selling the house Aiden has lived in for most of his life and she is concerned that this is contributing to his anxiety/decrease in school performance.

Vitals:

HR: 85      BP: 106/68    T: 97.9    RR: 17   SPO2: 99%    H: 59.5″ W: 105lbs 3oz

PMH:

Eczema, ADHD, Anxiety, Reactive Airway Disease, Seasonal Allergies

PSH:

None

Medications:

Focalin XR 10mg

Adderall 5mg PRN

Albuterol PRN

Claritin PRN

Social History:

Lives with mom part-time and dad part-time. Has two sisters, ages 10 and 5. 2 dogs at home. Plays soccer during the spring and summer, but otherwise no interest in sports. Active in the school band. Reports few close friends.

ROS:

General: Well Appearing, no acute stress noted. Denies fever, weight loss/gain, change in activity level.

Neuro: Denies HA, trauma, LOC, seizure activity, developmental delays

HEENT: Denies change in vision, hearing, photo/phonophobia, runny nose, ear pain,

sore throat, neck pain

CV: Denies shortness of breath, sweating, color changes with feeding, chest pain,

palpitations, recent history of murmur, fainting, or dizziness with activity

Respiratory: Denies cough, wheezing, shortness of breath (triggers)

GI: +Constipation; Denies nausea, vomiting (bloody/bilious), diarrhea, hematemesis,

hematochezia, or melena; describe stooling habits

GU: Denies ysuria, frequency, urgency, hematuria,  sexual activity, STI

exposure

Endo: Denies olyuria/polydipsia, heat/cold intolerance, growth pattern

MS: Denies myalgias, arthralgias, trauma, limp, weakness

Skin: Denies Rashes, bruising, petechiae

Psych/behavior: +Decreased attention span, +decreased energy level, +GAD7, +PSQ9