General Paediatrics Consultation

Problem List

1. Attention-Deficit/Hyperactivity Disorder (ADHD), combined presentation
2. Oppositional Defiant Disorder (ODD)
3. Mild intermittent asthma

Medications

1. lisdexamfetamine (Vyvanse®) 30 mg PO daily in AM
2. melatonin 3 mg PO QHS PRN insomnia
3. salbutamol (Ventolin®) 100 mcg/puff MDI 2 puffs INH Q4H PRN SOB/wheeze

Discontinued Medications

1. methylphenidate ER (Concerta®) 36 mg PO daily - Discontinued due to severe afternoon rebound irritability and emotional lability.

Chief Complaint

Follow-up for ADHD management, persistent afternoon emotional dysregulation, and academic difficulties.

History of Present Illness

I was pleased to review the patient, who is now 8 years old. They attended with Sarah Miller, his mother. Leo was diagnosed with ADHD combined presentation 14 months ago and switched to lisdexamfetamine 30 mg three months ago. Sarah reports that his morning symptom control is adequate, with his teacher noting improved focus and reduced classroom disruptions before 13:00. However, Leo experiences a marked decline in focus and impulse control by mid-afternoon, leading to frequent peer conflicts. He had one in-school suspension last month for throwing a chair when frustrated with a math assignment. He currently has an Individual Education Plan (IEP) in place, which provides preferential seating, movement breaks, and access to a quiet workspace, though he often refuses to utilize the quiet room due to social embarrassment.

At home, the afternoons are particularly challenging for the family. Sarah describes daily emotional meltdowns and verbal aggression directed toward his younger sister between 16:00 and 18:00, which she attributes to medication wear-off and hunger. Leo exhibits significant task-avoidant anxiety regarding afternoon homework, refusing to sit for more than five minutes without crying or ripping up his worksheets. He recently dropped out of his recreational soccer league because he struggled to follow the coach's instructions and became aggressive when losing. Sarah admits to feeling overwhelmed and exhausted, noting high levels of parental stress and marital strain as she and her husband, David, frequently disagree on disciplinary strategies.

Leo is currently supported by an occupational therapist, Chloe Tremblay, at Oakville Kids Clinic, whom he sees biweekly to work on sensory regulation and emotional coping strategies. He also began seeing a registered psychologist, Dr. Mark Evans, at Halton Family Psychology once a month to address his frustration tolerance and anxiety, alongside parent management training for Sarah and David. His primary care is managed by his family physician, Dr. Priya Patel, in Mississauga.

ROS

• Constitutional: Decreased appetite during the day with compensatory evening hyperphagia; weight stable. No fever or fatigue.
• HEENT: Normocephalic; no visual or hearing concerns.
• Respiratory: Occasional nocturnal cough once a month; no recent wheezing or rescue inhaler use in the past 6 weeks.
• Cardiovascular: No chest pain, palpitations, syncope, or exercise intolerance on stimulant therapy.
• Gastrointestinal: Occasional mild abdominal pain in the mornings after taking medication; normal daily bowel movements.
• Neurological: No tics, tremors, seizures, or headaches.
• Psychiatric: Initial insomnia (takes 60 minutes to fall asleep without melatonin); no depressed mood, self-harm, or suicidal ideation.

Birth History

Born at 39+2 weeks gestation via uncomplicated spontaneous vaginal delivery. Birth weight 3.4 kg. No NICU admission; discharged home on day 2 of life.

Past Medical History

• Mild intermittent asthma, diagnosed at age 4, well-controlled without controller therapy.
• Simple febrile seizure at age 18 months; no recurrence.
• Distal radius buckle fracture (left) at age 6 following a fall from monkey bars; healed without sequelae.

Past Surgical History

• Bilateral myringotomy and tympanostomy tube insertion at age 2 for recurrent acute otitis media; tubes extruded spontaneously without complications.

Immunizations

Up to date per the Ontario publicly funded immunization schedule, including DTaP-IPV, MMR-V, and annual influenza vaccine.

Medications

• lisdexamfetamine (Vyvanse®) 30 mg PO daily
• melatonin 3 mg PO QHS PRN
• salbutamol (Ventolin®) 100 mcg/puff MDI 2 puffs INH Q4H PRN

Allergies

amoxicillin (generalized maculopapular rash)

Family History

• Father (David, 38): Diagnosed with ADHD in childhood; hypertension.
• Mother (Sarah, 36): Generalized anxiety disorder.
• Sister (Maya, 5): Healthy, neurotypical.

Social History

Lives in a single-family home in Oakville, Ontario, with both parents and his 5-year-old sister. Father works as an accountant; mother works part-time as a graphic designer. Grade 3 student in a regular classroom stream. No smoke exposure in the home. One family dog.

Diet

Picky eater; prefers carbohydrates and processed snacks. Skips most of his school lunch due to stimulant-induced appetite suppression, then consumes large portions at dinner and before bed. Drinks 2 cups of 2% milk daily; adequate water intake.

Development

Met early gross motor and fine motor milestones on time (walked at 12 months, pincer grasp at 10 months). Mild expressive speech delay noted at age 2, which resolved following 6 months of community speech-language pathology intervention. Strong parental bonding, though parent-child interactions are currently strained by oppositional behaviours.

Physical Exam

Vitals

• Temp: 36.8 °C
• HR: 84 bpm
• RR: 18 breaths/min
• BP: 102/64 mmHg
• SpO2: 99 % on room air

Growth Parameters

• Weight: 25.4 kg (45th percentile)

• Height: 128.0 cm (55th percentile)

• BMI: 15.5 kg/m² (40th percentile)

• General: Alert, active, fidgety in chair, interrupts conversation frequently, but cooperative with the physical exam.

• HEENT: Normocephalic, atraumatic. Tympanic membranes pearly grey bilaterally; no fluid or tubes present. Oropharynx clear, tonsils 1+ bilaterally.

• Cardiovascular: Regular rate and rhythm, normal S1 and S2, no murmurs, gallops, or rubs. Femoral pulses 2+ bilaterally, capillary refill < 2 seconds.

• Respiratory: Clear to auscultation bilaterally, good air entry throughout, no wheezes or crackles.

• Abdomen: Soft, non-tender, non-distended, normoactive bowel sounds, no hepatosplenomegaly.

• Musculoskeletal: Normal gait, full range of motion in all extremities, normal muscle tone and bulk.

• Neurological: Cranial nerves II-XII intact. Deep tendon reflexes 2+ and symmetric. No motor or vocal tics observed.

Labs

• 14/02/2026 09:15: CBC normal (Hb 132 g/L, WBC 6.8 x 10^9/L, Plt 285 x 10^9/L)
• 14/02/2026 09:15: Ferritin 34 ug/L
• 14/02/2026 09:15: TSH 2.1 mIU/L

Diagnostic Imaging

• 12/05/2024: X-ray Left Wrist - Buckle fracture of the distal radius metaphysis; normal alignment.

Assessment

Leo is an 8-year-old male with combined-type ADHD and ODD who presents with suboptimal afternoon symptom control and significant evening rebound irritability on lisdexamfetamine 30 mg daily. His growth parameters and cardiovascular status remain stable on stimulant therapy, though daytime appetite suppression is contributing to his late-afternoon emotional dysregulation.

Plan

1. Increase lisdexamfetamine (Vyvanse®) to 40 mg PO daily in AM to improve symptom coverage duration and reduce mid-afternoon wear-off.
2. Initiate guanfacine XR (Intuniv XR®) 1 mg PO QHS to target evening rebound irritability, oppositional behaviours, and initial insomnia; counselled mother on potential side effects including sedation, hypotension, and risk of rebound hypertension if stopped abruptly.
3. Discontinue melatonin once guanfacine XR is initiated.
4. Provide high-calorie, nutrient-dense breakfast prior to morning medication administration and pack a high-protein snack for 14:30 at school.
5. Continue biweekly occupational therapy with Chloe Tremblay and monthly psychology sessions with Dr. Mark Evans, focusing on parent management training.
6. Provide a letter to the school administration supporting the current IEP and recommending scheduled sensory breaks at 13:30 prior to typical behavioural escalation.

Disposition

Discharged home in the care of his mother. Follow-up scheduled in the General Paediatrics clinic in 6 weeks for a blood pressure check and medication efficacy review, or sooner if adverse effects occur.