Chief Complaint
Medication management for ADHD, with afternoon wearing off and falling behind on homework in 9th grade.

History of Present Illness (HPI)
Sonny Walker is a 14-year-old male with ADHD, combined presentation, diagnosed in 2019, and generalized anxiety disorder who presents with his mother for medication management six weeks into 9th grade.

His mother reports lisdexamfetamine works well in the morning but wears off by 3 PM, and homework now takes until 10 PM. She notes irritability between 4 and 6 PM. Sonny says he forgets to write down assignments and has two missing grades in biology. He denies low mood, chest pain, tics, or trouble falling asleep. He states, "My brain is great until lunch, then it's like the battery dies."

Collateral Information
Mother (in person): Mornings run smoothly. After school, he snacks, plays video games, and resists starting homework. Arguments about homework happen four nights a week.

English Teacher (Vanderbilt follow-up form, 10/2026): Focused and participates well in first period. Turns in work late about once a week.

Biology Teacher (email via mother, 10/2026): Often off task in seventh period and missed two lab write-ups.

ADHD Treatment History
2019 (Age 7): Diagnosed with ADHD, combined presentation, after parent and teacher Vanderbilt scales were positive for 8 of 9 inattentive and 8 of 9 hyperactive-impulsive items. Symptoms first caused impairment in kindergarten. Completed parent training in behavior management. 504 plan started.

2019 to 2021: Methylphenidate extended-release titrated from 18 mg to 27 mg with good response.

2021: Weight fell from the 50th to the 15th percentile with poor lunch intake. Switched to lisdexamfetamine 20 mg, then 30 mg, with appetite and weight recovery.

2023: Eye-blinking tic for three months that resolved without a medication change.

2024: Test anxiety and worry about grades. Diagnosed with generalized anxiety disorder. Completed 12 sessions of CBT, with GAD-7 improving from 11 to 5.

2025: Lisdexamfetamine increased to 40 mg for 8th grade workload, with good school-day coverage.

08/2026: Started 9th grade with a longer day, seventh-period biology, and more homework.

Behavioral Medication History
Methylphenidate extended-release (2019 to 2021): 18 mg, then 27 mg. Effective. Discontinued for appetite suppression and weight loss.
Lisdexamfetamine (2021 to present): 20 mg, then 30 mg in 2021, and 40 mg since 2025. Effective until about 3 PM. Mild lunch appetite suppression.

Current Medications
Lisdexamfetamine 40 mg every morning at 6:45 AM
Multivitamin daily

Past Medical History

• ADHD, combined presentation (diagnosed 2019)
• Generalized anxiety disorder (diagnosed 2024)
• Provisional tic disorder (2023), resolved
• Mild intermittent asthma, no inhaler use in two years

Family History

• Father with ADHD diagnosed in adulthood
• Mother with generalized anxiety disorder
• Maternal uncle with Tourette syndrome
• No family history of sudden cardiac death before age 50, arrhythmia, or cardiomyopathy

Family Details (current)
Lives with his mother, father, and 11-year-old sister. Both parents work full time. His mother manages his medication and school communication.

Social History
School: 9th grade at a public high school with a 504 plan for extended time and preferential seating.
Activities: Junior varsity cross-country and guitar lessons.
Screen Time: About 3 hours daily, mostly video games after school.
Sleep: Lights out at 10:30 PM, asleep within 20 minutes, awake at 6:30 AM.
Substance Use: CRAFFT 0. Denies vaping, alcohol, or cannabis.
Medication Safety: A classmate asked to buy his pills last month. He refused and told his mother.

Rating Scales and Screening
Vanderbilt Parent, Inattentive Items Positive: 2019: 8 of 9. 2024: 3 of 9. 10/2026: 5 of 9.
Vanderbilt Parent, Hyperactive-Impulsive Items Positive: 2019: 8 of 9. 2024: 2 of 9. 10/2026: 2 of 9.
Vanderbilt Teacher (English), Inattentive Items Positive: 10/2026: 3 of 9.
Vanderbilt Performance Items: Problematic in homework completion and organization. Average in classroom behavior and peer relationships.
GAD-7: 2024: 11. 2025: 5. 10/2026: 7, mild.
PHQ-A: 10/2026: 4, minimal.
Interpretive Summary: Inattentive symptoms have risen since 2024, mainly in the afternoon and evening, consistent with medication wearing off rather than loss of overall response. Hyperactivity remains well controlled.

Growth and Vital Sign Monitoring
Weight Percentile: 50th (2019), 15th (2021), 35th (2024), 40th (10/2026)
Height: 165 cm (45th percentile)
Weight: 52 kg (40th percentile)
BMI: 19.1 kg/m² (45th percentile)
BP: 114/70 mmHg, normal for age
HR: 84 bpm

Medication Side Effect Review
Appetite: Light lunch, large after-school snack, and full dinner.
Sleep: Falls asleep within 20 minutes.
Mood: Irritability from 4 to 6 PM, consistent with afternoon rebound.
Cardiac: No chest pain, palpitations, or fainting.
Tics: None since 2023.
Prescription Drug Monitoring Program: Reviewed today. Single prescriber and pharmacy, with fills every 30 days and no early refills.

Mental Status Exam
Appearance: Well groomed, wearing his cross-country team shirt.
Behavior: Cooperative, engaged, and mildly fidgety, tapping his foot through the visit. Less restless than at prior visits.
Speech: Normal rate and volume.
Mood: "Fine, just stressed about bio."
Affect: Euthymic and reactive, with humor.
Thought Process: Linear and goal-directed.
Thought Content: Focused on grades and cross-country. No suicidal or homicidal ideation.
Perceptual Disturbances: No hallucinations.
Cognition: Alert and oriented. Lost track of one question during a long answer.
Insight: Good. Recognizes when his medication wears off.
Judgment: Good, shown by refusing to sell his medication.
Impulse Control: Good in clinic.

Risk Assessment
Risk Factors: ADHD with comorbid anxiety, controlled stimulant prescription, and a recent request from a peer to buy his medication.
Protective Factors: Supportive parents, strong school and sports engagement, no substance use, and no suicidal ideation.
Assessment: Low acute risk. Outpatient care remains appropriate.

Plan
Sonny Walker is a 14-year-old male with ADHD, combined presentation, showing good morning response to lisdexamfetamine with afternoon wearing off that is affecting homework and seventh-period classes.

1. ADHD, Combined Presentation
Parent-reported inattentive symptoms have risen from 3 to 5 of 9 since 2024, concentrated after 3 PM. Morning control is strong, and increasing his morning dose risks further appetite suppression, which caused weight loss in 2021. A short-acting afternoon dose targets the gap more precisely.

• Continue lisdexamfetamine 40 mg every morning
• Add dextroamphetamine 5 mg at 2:30 PM on school days to cover seventh period and homework
• Reviewed stimulant side effects, including appetite, sleep, heart rate, mood, and tics
• Repeat parent and biology teacher Vanderbilt scales in 4 weeks

2. Generalized Anxiety Disorder
GAD-7 has risen from 5 to 7 with stress about grades, still in the mild range.

• Booster CBT sessions focused on school stress
• Repeat GAD-7 at the next visit

3. School Supports

• Updated letter to the school requesting an addition to his 504 plan for daily planner checks by his advisor and teacher-signed assignment confirmation in biology
• Homework start time of 5 PM with a 15-minute break every 45 minutes

4. Growth and Cardiovascular Monitoring
Weight has recovered to the 40th percentile, and blood pressure and heart rate are normal.

• Encourage a protein-rich breakfast before his morning dose and a dinner snack
• Recheck weight, blood pressure, and heart rate at each visit

5. Medication Safety and Diversion Prevention

• Praised Sonny for refusing to sell his medication
• His mother will keep the afternoon dose and dispense it after school
• Stored in a locked box at home
• Discussed driving safety ahead of his learner's permit next year, including timing medication to cover driving

6. Follow Up

• Return in 4 weeks to review afternoon dose response and rating scales
• 30-day prescriptions with PDMP review before each fill

Ordered

Medications:
Lisdexamfetamine 40 mg every morning, 30-day supply
Dextroamphetamine 5 mg at 2:30 PM on school days, 30-day supply

Referrals:
Booster CBT sessions with his therapist

Documents:
Updated 504 plan letter to the school
Vanderbilt follow-up forms for parent and biology teacher

Procedures Today:
Vanderbilt parent and teacher scales scored and interpreted
GAD-7 and PHQ-A screening
Prescription drug monitoring program review

Billing Considerations
Established patient E/M visit at moderate complexity for prescription drug management of a controlled substance, with standardized behavioral assessment instruments billed per instrument and the visit-complexity add-on for ongoing longitudinal care.