PEDIATRIC NEUROLOGY CLINIC CONSULT_____________________
Patient Name: Grace Pereira
PCP: Reed Phillips, MD
Patient ID: 017990
Date of Exam: 05/05/2015
Reason for Visit: Follow-up of behavior, patient accompanied by mother, records are unavailable.
HISTORY: Grace a 7-year-old girl has a history of severe behavioral problems, ADHD, bipolar disorder, borderline mental retardation, and significant past medical history of congenital hydrocephalous associated with myelination defect on MRI. Mother records no new concerns. Mother notes some brief improvements in the patient’s impulsiveness and distractibility after starting Neurontin. However, she feels that it is no longer effective. Since the last visit blood tests were obtained, and an MRI with repeat MR spectroscopy. Also, consultation with ophthalmology revealed normal hyperopia for age. Mother continues to express concern for the child’s violent behavior but notes that overall she is doing well in school. She has some difficulties with the arithmetic but she seems to be reading at or above grade level. Speech is sometimes disconnected and nonsensical, otherwise articulation is within normal limits. Patient continues to participate in special education at school, as well as, anger management group sessions at school, at least weekly. She is managed by a psychiatrist for psychotropic medications and sees a child phycologist for behavioral management therapy.
MEDICATIONS: Abilify 2.5 mg p.o. b.i.d Neurontin 100 mg p.o. b.i.d.
PHYSICAL EXAMINATION: VITAL SIGNS: WT 23.6 kg, HT 118 cm, HC 50 cm which is approximately the 25th to 30th percentile for age, and is stable since last visit. T 98.9°F, HR 113, BP 105/67, RES 22, O2 Sat 97% on room air. GENERAL: Patient is awake and alert, pleasant and cooperative, well appearing in no acute stress without dysmorphic features. HEENT: Normocephalic, atraumatic. Pupils are equal round and...
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