NF Psychiatriac assessment note

Telehealth Appointment **Time:** 10:00 AM **Date:** 1 November 2024 **Present:** Patient alone **Referral Details** - Referred by Dr. Sarah Jones, GP, due to concerns about inattention and hyperactivity in school. Previous assessments include a Conners' Rating Scales completed by the patient's teacher, indicating elevated scores for ADHD symptoms. - Collateral history obtained from the school psychologist, who reported significant difficulties with focus and task completion in the classroom. **Demographics** - [Patient Name], a 10-year-old male, identifies as male. He lives with both parents and has one younger sibling. He is currently in Year 5 at a local primary school. He enjoys playing video games and riding his bike. **Presenting Issues** - The patient reports difficulty concentrating in class, feeling restless, and often blurting out answers. He states, "I can't sit still, and I get bored easily." The symptoms have been present for approximately two years, with increasing intensity over the past six months. He reports that these issues are impacting his schoolwork and relationships with peers. - DSM-5 ADHD hyperactivity/impulsivity symptoms present: Fidgets with hands or feet or squirms in seat (moderate severity), difficulty leaving seat in situations when remaining seated is expected (moderate severity), often talks excessively (moderate severity). These symptoms have been present for over 6 months and significantly impact his ability to focus in class and follow instructions. - DSM-5 ADHD inattentive symptoms present: Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (moderate severity), has difficulty sustaining attention in tasks or play activities (moderate severity), is often easily distracted by extraneous stimuli (moderate severity). These symptoms have been present for over 6 months and significantly impact his ability to focus in class and follow instructions. - No symptoms relevant to major depressive disorder or anxiety disorders were reported. - No suicidal ideation or self-harm reported. - Sleep: Sleeps approximately 9 hours per night. Diet: Eats a balanced diet. Appetite: Good. Exercise: Plays outside for 1-2 hours per day. - Screen and social media use: Uses screens for approximately 2-3 hours per day, primarily for gaming. No social media use reported. **ADHD Symptoms** - DSM-5 inattentive symptoms present: Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities; has difficulty sustaining attention in tasks or play activities; is often easily distracted by extraneous stimuli. - DSM-5 hyperactivity and impulsivity symptoms present: Fidgets with hands or feet or squirms in seat; difficulty leaving seat in situations when remaining seated is expected; often talks excessively. **Features of Autism Spectrum Disorder** - No difficulties in verbal and non-verbal communication were reported. - No restricted, repetitive behaviours, interests, or activities were reported. - No sensory sensitivities were reported. - Does not meet DSM-5 criteria for autism spectrum disorder. **Mental Health History** - No previous psychiatric diagnoses, therapies, self-harm behaviours, or hospitalisations reported. - No previous treating clinicians reported. **Medical History** - No past or current medical conditions reported. **Objective** - Vital signs: Not assessed during telehealth appointment. - Physical or mental state examination findings: Not assessed during telehealth appointment. - Completed investigations and their results: Conners' Rating Scales completed by the teacher, indicating elevated scores for ADHD symptoms. **ADHD-Related Cardiac History** - No relevant cardiac problems, family history of sudden cardiac death, or hypertension reported. **Medication History** - No current or past psychiatric or non-psychiatric medications reported. **Allergies** - Nil reported **Drug and Alcohol History** - No current or past use of drugs or alcohol reported. **Forensic History** - Nil reported. **Family History** - There was no reported family history of mental health conditions or suicide. **Developmental History** - Details about patient’s birth, parents, complications, illnesses: Normal birth, no complications. Parents are married and in a stable relationship. - Comment on developmental milestones, and any delays or treatments: Met all developmental milestones. - Describe early attachments and childhood temperament: Described as a happy and active child. - Mention any early trauma or significant events: No early trauma or significant events reported. - Describe school experience: Currently in Year 5, experiencing difficulties with focus and task completion. - Include history of behavioural difficulties at home or school: Some behavioural difficulties at school, including difficulty following instructions and blurting out answers. - Include ADHD symptoms noted in childhood: Some ADHD symptoms noted in childhood, including difficulty concentrating and hyperactivity. **Functioning** - Current school functioning is impaired due to difficulties with attention and hyperactivity. The patient is struggling to keep up with schoolwork and is experiencing social difficulties with peers. **Mental State Examination** - Engagement: Cooperative and engaged during the interview. - Appearance: Appropriate for age. - Speech: Normal rate and rhythm. - Thought process: Goal-directed. - Mood and affect: Reported mood is generally happy, affect is congruent. - Insight: Demonstrates some insight into his difficulties. - Judgement: Appears to have good judgement. - Cognition: Age-appropriate cognitive functioning. - Relevant negatives: No evidence of psychosis or suicidal ideation. **Impression** - Detailed biopsychosocial formulation referencing symptoms, diagnosis, social/environmental factors: The patient presents with significant symptoms of inattention and hyperactivity, impacting his school performance and social interactions. The symptoms have been present for over six months and meet the criteria for ADHD, combined presentation. Social and environmental factors include the patient's family support and the school environment. - Include all relevant DSM-V diagnoses and criteria met: ADHD, combined presentation. - Document relevant symptoms absent: No symptoms of major depressive disorder or anxiety disorders were reported. - Identify differential diagnoses: Rule out other potential causes of inattention, such as learning disabilities or underlying medical conditions. - Describe impacts on functioning and relationships: The patient's ADHD symptoms are significantly impacting his school performance and relationships with peers. - Comment on whether ADHD symptoms are secondary to another disorder or substance use: Based on the available information the ADHD symptoms are not secondary to a separate medical or psychiatric illness or substance use. - Include whether ADHD symptoms were present in early childhood or not confirmed: ADHD symptoms were noted in early childhood. - Comment on prognosis, protective factors, and patient strengths: The prognosis is good with appropriate treatment and support. Protective factors include a supportive family and a positive attitude. Patient strengths include his intelligence and his willingness to engage in treatment. - Comment on risk to self or others: There were no immediate risks identified. **Today we discussed:** - Treatment planning point 1: Discussed the diagnosis of ADHD and the impact of symptoms on his life. - Treatment planning point 2: Discussed treatment options, including medication and behavioural therapy. - Treatment planning point 3: Discussed strategies for managing ADHD symptoms at home and school. **Recommendations for GP** - Please continue to monitor the patient's progress and provide ongoing support. **Recommendations for Patient** 1. Begin medication as prescribed. 2. Attend follow-up appointments as scheduled. 3. Consider engaging with a therapist for behavioural therapy. Please contact [clinic contact email address] if you require any clarification or assistance.