Patient: A.F. Age: 8 Gender: Male Race: Caucasian
SUBJECTIVE
CC: The mother to the eight-year old boy states that her son has been displaying abnormal behavior in that he is continually moving around and is unable to concentrate for long on any task. She has also received reports from school that the boy is excessively disruptive and cannot finish work given to him by the teachers.
HPI: The patient is an 8 year-old Caucasian male child with hyperactivity, inattention, and impulsivity that started one month ago and is becoming more intense. It is not associated with a lack of understanding instructions on the part of the child. The mother reports that the child is also not really defiant. The symptoms occur at any time of the day and are only momentarily relieved by reprimanding. The mother rates the severity of the symptoms at 8/10 on a scale of 1-10 ADHD SOAP Note example.
Current medications: The child is not on any medications at the moment.
Allergies: He is allergic to penicillin. Mother reports that he is not allergic to any other medication, foods, or environmental factors.
Past Medical History: He had pneumonia at age 3 which was successfully treated as an in-patient. Given BCG, tetanus/ Diptheria/ Pertussis, and measles vaccines (2012-2013), influenza vaccine (2017), and pneumonia vaccine (2015). The mother reports that he has no history of malaria or meningitis. He also has not suffered any head injury in the past.
Social History: The boy is the second born in a family of four. The elder sibling is a girl aged twelve and she has no medical or mental problems. The father is a computer engineer and the mother is a nurse. The father smokes but drinks only occasionally. The mother neither drinks nor smokes.
Family History: There is no history of mental illness in the family, both from the father’s side and the mother’s side.
Review of Systems (ROS)
Constitutionals: Patient denies feeling hot/ warm. Mother also denies any weight loss in the boy. She however reports excessive hyperactivity, impulsivity, and inattention not accompanied by lack of comprehension. He has no sleep difficulties.
HEENT: The boy reports no dry eyes, itching, or pain. He has no photophobia. He reports no hearing loss, no tinnitus, and is not sneezing. He also has no runny nose and no sore throat.
Respiratory: He has no difficulty in breathing, is not coughing, and has no phlegm.
Cardiovascular: He has no chest discomfort, pain, or palpitations.
Gastrointestinal: Mother reports no vomiting, lack of appetite, or diarrhea.
Genitourinary: The boy denies any burning sensation on urination. No polyuria.
Musculoskeletal: He denies any muscle pain or stiffness.
Neurologic: He denies any headache, instability while walking, numbness, or a change in bladder and/ or bowel control.
Psychiatric: Mother reports that the child has a history of abnormal lack of concentration and hyperactivity. She however denies noting any depressive or anxiety symptoms in him.
Hematologic/ Lymphatic: Both mother and son deny any abnormal bleeding or fatigue. No enlarged nodes.
Endocrine: Mother and son deny excessive urination (polyuria) or excessive water intake (polydipsia). They also deny excessive sweating or heat intolerance.
Allergic/ Immunologic: Mother denies any history of eczema or asthma. Also denies any other seasonal allergies.
OBJECTIVE
Constitutional: The boy is well-groomed and well-nourished. Vital signs: Heart rate: 90; Respiratory rate: 20; Temperature: 98.6°F; Blood pressure: 110/70; Height: 51 inches; Weight: 56 lb; BMI: 15.1 (BMI-for-age at the 33rd percentile). The child has healthy weight (CDC, 2018).
HEENT: Head normocephalic and atraumatic with normal contours. Both pupils equal, round, and reactive to light and accommodation (PERRLA). Intact extraocular muscles. Nasal sinus passages non-tender on palpation. Intact tympanic membrane with no discharge or redness. No halitosis. No exudates in throat.
Neurologic: Crani
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