Patient Note (James)
James
(Patient ID 039)
| Name: James | Age: 7 | Gender Identity: Male | Race: Caucasian |
|
Diagnosis: ADHD-combined presentation |
Insurance: Cigna | ||
| Current Medical History: James has a diagnosis of ADHD. | |
| Past medical/surgical history: James had one minor surgery at 3 years of age. | |
| Birth history: James was born at 40 weeks, 6 days as a result of an emergency c-section due to fetal distress. He weighed 7lbs 9oz |
| Parental Concerns: James lives at home with mom, dad, and brother who is 3.5 months younger than him. He shares a bedroom with his brother. James is an inquisitive, athletic, and smart boy who is always on the go. He frequently complains of being bored during down time. James frequently has emotional outbursts when he is frustrated or upset, especially if he is also hungry. | |
| School: James is in third grade and has a 504 plan for accommodations related to his diagnosis of ADHD (e.g., preferential seating, recheck for understanding, use of fidgets). He is performing above grade level in all academic areas and is on the A-Honor Roll. James is working toward listening and following directions consistently within the classroom setting. | |
|
Milestones: Rolling: supine to prone at 2 weeks; prone to supine at 4 weeks Crawling: 4 months Prone to Sitting: 6 months Standing: 7 months Walking: 10 months Potty trained: 14 months Riding a bike: 2.5 years |
|
| Interests: James is an athlete and loves being outside and playing sports, including soccer, basketball, tennis, and baseball. He enjoys reading chapter books, playing board games, doing science experiments, and playing with friends. |
Ritalin XR 15mg
Intuniv 2mg
Melatonin 10mg
Daily multivitamin
Disclaimer: Although the individuals in ICE videos are real patients, the exact history has been altered to protect their identities.