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CI case 1 Jason Smith (J.S) - 5/4/09 3 y.

o CC- needs physical and his preschool teacher says he is behind the other kids Things to accomplish at this visit?? -milestones -PMH- issues at birth? Nutritional issues or previous diagnoses? -plot height and weight on growth charts -Social interactions? Home environment? -Physical exam -Anticipatory guidance Differentials right off the bat: -ADHD * -ODD -Autism/Aspergers * -Learning D/o -FTT -anxiety * -hearing deficit HPI Qs-What has the teacher said? 8 mos ago, difficulty playing w/ others, becomes frustrated easily, sometimes will throw things at others causing pain to the other children. Pretty sure he isnt intentionally causing pain -How does he react when you give him directions? Seems to want to follow them, but gets distracted and has a hard time. When he gets scolded he feels regret -Development up until this point? Never had any issues until this point -Is it just at school, or is it at home as well? Always going at home too, always running around. Acts out in public places as well. When schedule gets changed, he gets upset -Household changes? Likes to play with his siblings, but gets impatient and gives up. Just recently started going to preschool. Parents have gotten divorced -Behavior corrections? Probably inconsistent between the 2 parents and the teacher. Dad has him every other weekend and on Wed nights. Behavior is worse when he gets back from dads -Hard to tell progress in pre-K because of his behavior -Sleep habits? 8 hours a night, sometimes an hour nap

-How has he been communicating? He often initiates play, has positive interactions, but cant focus for very long so he gets frustrated and stops playing -Why now? Why has it been 8 mos since the problem started before bringing him in? PMH QsWere there any issues with birth? Full-term, no OB issues, APGAR scores 9 and 9, newborn screening All negative Any previous diagnoses? No childhood illnesses, has had all his check-ups Immunizations? Up to date Maternal Smoking/Drug/Alcohol use- None Typical daily nutrition3 meals/day. Cereal for breakfast, PB and J with fruit or veggie for lunch, dinner is meat/potatoes. No juice or sodas Hearing and Vision- ? Surgeries/Hosp.- No Allergies- None Infancy- Fussy, not excessive, no routine schedule, breastfed for 6 wks, formula til 1 year Babysitting- maternal grandparents Siblings w/symptoms? Sister- 8, brother 5- both healthy Getting him to go to sleep is difficult Dental visits? These should start soon Supplements? FMH-Dad has ADD and Anxiety disorder -Mom has no significant PMH -Cardiovascular- no -DM- no -Autism Spectrum? No and no PDD -Psychiatric- None Milestones? normal -ROSGeneral- weight loss/gain, sleeping issues, appetite changes HEENT-ear infections, hearing, headache, head trauma Neuro- hand/eye coordination, tremors/tics/seizures

Psych- mood, anxiety, withdrawn, desire to interact decreased? Napping more? Nervousness/stress about going to school, feelings about divorce? Cardiac- out of breath, flushed Differentials nowADHD Aspergers Anxiety Adjustment/stress disorder Physical ExamGeneral Assessment- WDWN male preschooler, no acute distress, loudly running around exam room playing with one thing than another thing while mother tries to get him to quietly sit down. Height- 98 cm Weight- 14 kg (normal) Vitals- RR-14 (unlabored), pulse 78 (normal) Heart/lungs Teeth-anticipatory guidance for dentist Genitals- testicles descended, circumsized or not Neuro exam Differential now- ADHD What now? -referral -behavioral modification w/ parents- parental education, establish routine, get on same page with discipline and pos. reinforcement -find out what the disciplinary actions are at school and alter as needed -Conference with teacher and parents possibly -No official diagnosis of ADHD at this point, wait and see 3-6 months

if not responding- Adderall QAM 2.5 mg, can increase by 2.5mg/wk up to 40 mg/day give with food monitor sleep drug holiday 3 y.o anticipatory guidancedentist carseat- facing forward in backseat til either 5 y.o or 40 lbs helmet on tricycle

safety-proof house, water safety, sunscreen eating with utensils/table manners balanced diet/ no junk food hand-washing, hygiene <2 hours screen time independence stranger safety ROUTINE Write-up includes- CC and HPI but this can include PMH and FH Well-child check for 3 years old with appropriate growth and development Behavioral Disorder-NOS