Letter to Dr. Sarah Evans, GP
Visit Diagnosis/Symptom Complex:
1. Attention Deficit Hyperactivity Disorder (ADHD), Combined Presentation
2. Generalised Anxiety Disorder
Problem List
1. Chronic difficulty with academic focus and completion of tasks
2. Impulsivity leading to social difficulties
3. Restless sleep patterns
Current Medicines:
1. Methylphenidate 18mg, modified release, once daily in the morning
2. Sertraline 25mg, oral tablet, once daily in the evening
Education:
Patient is currently in Year 6 at Willow Creek Primary School. He receives additional support for literacy and numeracy twice a week in small group sessions.
Examination
Weight 32 kg
Height 135 cm
Blood Pressure 105/68 mmHg, within normal limits for age.
Plan
1. Continue current medication regimen; review efficacy and side effects at next appointment.
2. Recommend school-based behavioural strategies, including preferential seating and visual timetables.
3. Refer for cognitive behavioural therapy (CBT) to address anxiety symptoms.
4. Follow-up appointment scheduled in 6 weeks to assess medication response and progress with interventions.
Outcome
Today's appointment confirmed the need for ongoing management of ADHD and co-occurring anxiety. The patient and his mother were engaged and understood the proposed plan. Further intervention and follow-up are arranged.
Dear Colleagues
I was pleased to review Michael Jones who was brought to my community clinic by his mother, Mrs. Emily Jones. Michael was referred by your practice due to ongoing concerns regarding his attention, hyperactivity, and impulsivity in both home and school environments, which have been present for approximately three years and have significantly impacted his academic progress and social interactions.
Current Situation
Mrs. Jones describes Michael as a bright and energetic 10-year-old boy who struggles significantly with staying focused on tasks, particularly homework and classroom activities. She reports frequent instances of Michael interrupting conversations, difficulty waiting his turn, and often losing belongings. He often fidgets and struggles to sit still, even during preferred activities. Socially, he finds it challenging to maintain friendships due to his impulsivity, which sometimes leads to him saying or doing things without thinking. Mrs. Jones also notes that Michael often appears anxious, worrying excessively about school performance and social acceptance, which sometimes manifests as stomach aches before school.
In-Clinic Questionnaires
Michael self-reported feeling frustrated by his inability to concentrate and often feels misunderstood by his peers and teachers. He expressed a desire to do well in school but finds it very hard to stop his mind from wandering. He sometimes feels overwhelmed by tasks and tries to avoid them. He copes by retreating to his room to play video games, which he finds calming.
Mrs. Jones provided additional observations, clarifying that Michael's difficulties are pervasive across settings and have worsened over the last year, coinciding with the increased academic demands of Year 6. She noted that while he is intelligent, his output does not reflect his potential due to his struggles with organisation and sustained attention. She also highlighted his sensitivity to criticism.
Relevant background information includes a paternal history of ADHD, which Mrs. Jones believes contributes to Michael's presentation. There is no reported history of significant trauma; however, Michael experienced a brief period of bullying in Year 4, which led to increased social anxiety at the time.
Development
Michael met all early motor and speech developmental milestones within expected ranges. He was an early walker and talker. His primary school teachers first raised concerns about his attention and hyperactivity in Year 2.
Sleep
Michael struggles with falling asleep, often taking over an hour to settle. He wakes frequently during the night and experiences restless sleep. No medications are currently used to support sleep.
Past Medical History And Background
Born at full term via spontaneous vaginal delivery with no complications. No significant past medical conditions or hospitalisations. Up to date with all routine childhood vaccinations. No known allergies.
Family History
Michael lives with both parents and a younger sister, aged 7. His father has a diagnosed history of ADHD. There is a maternal history of anxiety disorder. No other significant family medical or mental health history reported.
ADHD Evaluation
Information From Mrs. Jones In August 2024
Strengths
Mrs. Jones reports Michael is creative, imaginative, and has a good sense of humour. He is very kind to animals and enjoys drawing and building Lego. He is very keen to please and responds well to positive reinforcement.
Challenges
Mrs. Jones highlighted significant challenges with task initiation and completion, organisation, and emotional regulation. She noted his forgetfulness and difficulty following multi-step instructions.
Information From The School In July 2024 And September 2024
Strengths
The school reported Michael's strong verbal reasoning skills and his eagerness to participate in class discussions when topics genuinely interest him. He is generally polite and well-mannered.
Challenges
The school's reports consistently highlight difficulties with sustained attention, particularly during independent work and group tasks. He struggles with completing assignments on time, often losing focus or becoming distracted by peers. His impulsivity sometimes leads to calling out answers without raising his hand or interrupting others. Academic performance is variable, with strong results in subjects he enjoys and struggles in those requiring sustained, rote learning.
Information From School - Received October 2024
Strengths
Recent reports indicate an improvement in Michael's participation in class discussions and a growing willingness to ask for help when he feels stuck. He continues to demonstrate creativity in art classes.
Challenges
Recent challenges include increased difficulty regulating emotions when frustrated, leading to occasional outbursts. Socially, he continues to struggle with turn-taking and listening to others, which affects his ability to maintain friendships. Academic challenges persist in subjects requiring meticulous attention to detail.
Conners parent, teacher, and self-report questionnaires gather information regarding a range of behaviours and symptoms. The scores indicate whether the observed symptoms are disproportionate to those expected for a child of the same age. T-scores greater than 70 for attention and hyperactivity or impulsivity in all settings indicate that the symptoms are significant.
Parents' Rating T Scores - October 2024
Inattention / Executive Dysfunction - 75
Hyperactivity - 72
Impulsivity - 70
Emotional Dysregulation - 68
School Work - 71
Peer Interactions - 65
Family Interactions - 60
Teachers' Rating T Scores - October 2024
Inattention / Executive Dysfunction - 78
Hyperactivity - 73
Impulsivity - 71
Emotional Dysregulation - 65
School Work - 74
Peer Interactions - 68
Self-Reported T Scores
Inattention / Executive Dysfunction - 62
Hyperactivity - 58
Impulsivity - 59
Emotional Dysregulation - 63
School Work - 60
Peer Interactions - 55
Family Interactions - 52
QB Test - September 2024
Michael underwent a Quantified Behavioural Test (QbTest) to objectively measure core ADHD symptoms. This computer-based test assesses attention, impulsivity, and motor activity against age- and gender-matched normative data.
The scores were as follows:
Activity Level - 2.5 (significantly elevated, indicating high motor activity)
Attention - 1.8 (below average, suggesting difficulty sustaining attention)
Impulsivity - 2.1 (elevated, indicating a tendency to respond without inhibition)
The overall QbTest findings are consistent with an ADHD profile, demonstrating objective difficulties in attention and impulse control, alongside increased motor activity, which aligns with both parental and teacher reports.
On Examination
During the consultation, Michael was observed to be restless, often fidgeting in his chair and tapping his feet. He frequently interrupted during discussions, particularly when excited about a topic. He had difficulty maintaining eye contact for extended periods but was otherwise cooperative and engaged when prompted. Affect was appropriate, and mood was euthymic but with underlying anxiety noted when discussing schoolwork. No gross neurological deficits were observed.
Conclusion And Plan
Based on the comprehensive assessment, including parent and teacher reports, self-report, and objective QbTest data, Michael continues to meet the diagnostic criteria for Attention Deficit Hyperactivity Disorder, Combined Presentation. His symptoms are pervasive, long-standing, and significantly impact his academic, social, and emotional functioning. Additionally, he presents with symptoms consistent with Generalised Anxiety Disorder, likely exacerbated by his ADHD challenges. The current plan involves continuing his prescribed stimulant medication, with a review in 6 weeks to optimise dosage and monitor for side effects. Referral for CBT is recommended to address his anxiety. We will also collaborate with the school to implement supportive strategies to aid his learning and behaviour. Psychoeducation regarding ADHD and anxiety management will continue for Michael and his family.
This letter relates to today's clinic appointment and was created using voice recognition software. Please contact the clinic should you have any questions or identify any inaccuracies. This is not for medico-legal purposes.
Letter to [Names and roles of all recipients of this letter] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. List each recipient separated by a comma.)
Visit Diagnosis/Symptom Complex: (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[A numbered list of the primary diagnoses or symptom complexes identified at this visit] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Never invent or infer a diagnosis. Present each diagnosis or symptom complex as a separately numbered item.)
Problem List
[A numbered list of chronic problems or diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading or list number.)
Current Medicines: (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[A numbered list of current medications including name, form, dosage, and frequency or instructions for use] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each medication as a separately numbered item.)
Education:
[The patient's educational setting and any relevant details about their schooling] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write as a full sentence, as its own paragraph.)
Examination
Weight [Patient's weight in kilograms] kg (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on a single line.)
Height [Patient's height in centimetres] cm (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on a single line.)
Blood Pressure [Patient's blood pressure reading and interpretation] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on a single line.)
Plan (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
[A numbered list of treatment plan items and recommendations] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each plan item as a separately numbered item.)
Outcome
[The outcome of the appointment and any follow-up arrangements] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write as a full sentence, as its own paragraph.)
Dear Colleagues
[A summary of the referral history and any prior contact with the service] (Only include the referral history and prior contact if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit that detail and write only: "I was pleased to review [patient's name or the patient] who was brought to my community clinic by [the accompanying person]." Write in narrative paragraphs.)
Current Situation
[The current presenting situation and concerns as described from the perspective of the accompanying person] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in narrative paragraphs.)
In-Clinic Questionnaires
[The patient's self-reported experiences, perceptions, and coping mechanisms discussed during the consultation] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in narrative paragraphs.)
[The accompanying person's additional observations and clarifications provided during the consultation] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in narrative paragraphs.)
[Relevant background information including trauma history and its relationship to current symptoms] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in narrative paragraphs.)
Development
[A summary of developmental milestones including motor and speech development and any relevant context] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in narrative paragraphs.)
Sleep
[A description of the patient's sleep patterns and any medications used to support sleep] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in narrative paragraphs.)
Past Medical History And Background
[A summary of birth history, past medical conditions, allergies, and vaccination status] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in narrative paragraphs.)
Family History
[A summary of family structure and relevant family medical or mental health history] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in narrative paragraphs.)
ADHD Evaluation
Information From [Source of information] In [Month and year of information] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this section entirely.)
Strengths
[A summary of the patient's strengths as reported by the stated source] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this subheading and content entirely. Write in narrative paragraphs.)
Challenges
[A summary of the patient's challenges as reported by the stated source] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this subheading and content entirely. Write in narrative paragraphs.)
Information From The School In [Month and year] And [Month and year] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this section entirely.)
Strengths
[A summary of the patient's strengths in the school setting as reported by the school] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this subheading and content entirely. Write in narrative paragraphs.)
Challenges
[A summary of the patient's challenges in the school setting including academic performance and support strategies as reported by the school] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this subheading and content entirely. Write in narrative paragraphs.)
Information From School - Received [Month and year] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this section entirely.)
Strengths
[A summary of recent strengths in the school setting as reported by the school] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this subheading and content entirely. Write in narrative paragraphs.)
Challenges
[A summary of recent challenges in the school setting including academic performance, social interactions, and emotional regulation as reported by the school] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this subheading and content entirely. Write in narrative paragraphs.)
(Only include the following paragraph if Conners questionnaires were explicitly mentioned in the transcript, contextual notes, or clinical note, else omit it entirely.)
Conners parent, teacher, and self-report questionnaires gather information regarding a range of behaviours and symptoms. The scores indicate whether the observed symptoms are disproportionate to those expected for a child of the same age. T-scores greater than 70 for attention and hyperactivity or impulsivity in all settings indicate that the symptoms are significant.
Parents' Rating T Scores - [Month and year of rating] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this section entirely.)
Inattention / Executive Dysfunction - [Score] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely.)
Hyperactivity - [Score] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely.)
Impulsivity - [Score] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely.)
Emotional Dysregulation - [Score] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely.)
School Work - [Score] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely.)
Peer Interactions - [Score] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely.)
Family Interactions - [Score] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely.)
Teachers' Rating T Scores - [Month and year of rating] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this section entirely.)
Inattention / Executive Dysfunction - [Score] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely.)
Hyperactivity - [Score] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely.)
Impulsivity - [Score] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely.)
Emotional Dysregulation - [Score] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely.)
School Work - [Score] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely.)
Peer Interactions - [Score] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely.)
Self-Reported T Scores
Inattention / Executive Dysfunction - [Score] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit this line.)
Hyperactivity - [Score] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit this line.)
Impulsivity - [Score] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit this line.)
Emotional Dysregulation - [Score] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit this line.)
School Work - [Score] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit this line.)
Peer Interactions - [Score] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit this line.)
Family Interactions - [Score] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit this line.)
QB Test - [Month and year of QB test] (Only include if the QB test was performed and explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this section entirely.)
[An explanation of the QB test and its context relevant to this patient] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this paragraph entirely. Write in narrative paragraphs.)
The scores were as follows:
Activity Level - [Score and interpretation] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely.)
Attention - [Score and interpretation] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely.)
Impulsivity - [Score and interpretation] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely.)
[A summary of the overall QB test findings and their clinical significance] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this paragraph entirely. Write in narrative paragraphs.)
On Examination
[Physical and behavioural examination findings observed during the consultation] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in narrative paragraphs.)
Conclusion And Plan
[Clinical reasoning, diagnostic conclusions, and rationale for the management plan including discussion of strategies and follow-up arrangements] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Never invent or infer a diagnosis. Write in narrative paragraphs.)
[A closing sentence summarising that the letter relates to today's clinic appointment, that it was created using voice recognition software, and providing contact details for any inaccuracies or questions] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write as a full sentence.)
