Patient B.
Treatment management supplemental chart notes
Patient: Mary Jones, age 9
Diagnosis: attention deficit hyperactivity disorder
| Visit #: 1 Date: May 22, 2006 CGI-S = 4 (moderately ill) CGI-I/Not Applicable (first visit) Predominant symptoms: inattention and hyperactivity at home and school Tolerability? N/A medication to begin tomorrow Medication? Stimulant initiated (name and dose) |
| Visit #: 2 Date: May 29, 2006 CGI-S=3 (mildly ill), CGI-I=3 (minimal improvement) Predominant symptoms: inattention and hyperactivity; both have lessened somewhat at home, per parent, though still quite noticeable at school Tolerability? no problems Medication? stimulant dose raised |
| Visit#: 3 Date: June 5, 2006 CGI-S= 2 (minimally ill), CGI-I=1 (very much improved) Predominant symptoms: teacher reported 1 episode of "fidgetiness" during math lesson (25 minute duration). Otherwise, no symptoms noted at school. Parent reports home hyperactivity and inattention symptoms have both been dramatically improved throughout the week. Tolerability? Eating less per parent; has lost 1 pound in past week. Medication: Maintain current dose; instruct parent to dose after large breakfast. |
| Visit #: 4 Date: July 7, 2006 CGI-S=1 (normal, not at all ill); CGI-I=1 (very much improved) Predominant symptoms: No symptoms of ADHD evident this week across multiple settings. Tolerability? No problems. Child's weight is maintained, and parent reports child's eating has normalized. Medication: Stimulant maintained at current dose. Breakfast prior to dosing will continue. |