W.V. is a 6 year old male
Chief Complaint
“I need some answers for my sons behavior per mom”
History of Present Illness
W.V. is a 6-year-old Hispanic boy that was seen today with mom and dad present at in person appointment.
Report from mom indicates that patient has been fidgeting a lot and repeats words and actions all the time
Worse after he has had sweets to eat.
Patient was quiet for a while in the chair but soon starts to fidget and play with his fingers (appears to be counting and
making letter signs repeatedly
Was able to answer to questions once mom repeated them in spanish
Appears to be delayed with responses due to being bilingual
Responses to questions asked on the Vanderb questionnaire by mom is in conclusive at this time as teacher at school is
unable to complete since school just started and she is not too familiar with patient
Asked for a couple more weeks in school before she can truly be in a position to complete it
We decided to proceed with starting patient on ADHD medications at this time due to symptoms observed by provider
and moms explanation at school concerns
Provider was able to assist with getting information for center close to home to assess for Autism
Mom was appreciative as she feels like she has not got much help from other professionals
Childrens hospital has a 2 year wait list for appointment at this time