Past Medical History
Patient has a history of asthma, diagnosed at age 5. No other significant medical history.
Past Psychiatric History including Suicidal Ideation
Patient denies any past psychiatric history or suicidal ideation.
Family History
Father has a history of ADHD. Mother has a history of anxiety. No other significant family history.
Medications
Patient is currently taking methylphenidate 10mg twice daily.
Schooling
Patient is currently in year 9 and is struggling to keep up with school work.
Developmental
Patient met all developmental milestones on time.
Forensic History
Nil mentioned.
Work History
N/a
Relationships
Patient reports good relationships with family and friends.
Sleep and appetite
Patient reports difficulty falling asleep and decreased appetite.
Milestones
Patient met all developmental milestones on time.
Mental Status Examination:
- Appearance: Patient is well-groomed and dressed appropriately for the weather.
- Behaviour: Patient is restless and fidgety during the consultation.
- Speech: Speech is rapid and pressured.
- Mood: Patient reports feeling frustrated and overwhelmed.
- Affect: Affect is congruent with mood, but labile.
- Thoughts: Patient reports racing thoughts and difficulty concentrating.
- Perceptions: No hallucinations or sensory misinterpretations reported.
- Cognition: Patient is oriented to person, place, and time. Concentration is impaired. Memory intact.
- Insight: Patient acknowledges difficulties with attention and hyperactivity.
- Judgment: Judgment appears intact.
Past Medical History
[Mention patient's past medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Past Psychiatric History including Suicidal Ideation
[Mention Past Psychiatric History including Suicidal Ideation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Family History
[Mention Family History] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Medications
[Mention medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Schooling
[Mention schooling] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Developmental
[Mention developmental issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Only if paediatric, if adult write "N/a")
Forensic History
[Mention forensic history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. If nil mentioned write "nil mentioned")
Work History
[Mention work history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Relationships
[Mention relationships] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Sleep and appetite
[Mention sleep and appetite] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Milestones
[Mention milestones] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Only if paediatric, if adult write "N/a")
Mental Status Examination:
- Appearance: [Describe the patient's clothing, hygiene, and any notable physical characteristics] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Behaviour: [Describe the patient's activity level, interaction with their surroundings, and any unique or notable behaviors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Speech: [Note the rate, volume, clarity, and coherence of the patient's speech] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Mood: [Record the patient's self-described emotional state, using their own words if possible] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Affect: [Describe the range and appropriateness of the patient's emotional response during the examination, noting any discrepancies with the stated mood] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Thoughts: [Assess the patient's thought process and thought content, noting any distortions, delusions, or preoccupations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Perceptions: [Note any reported hallucinations or sensory misinterpretations, specifying type and impact on the patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Cognition: [Describe the patient's memory, orientation to time/place/person, concentration, and comprehension] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Insight: [Describe the patient's understanding of their own condition and symptoms, noting any lack of awareness or denial] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Judgment: [Describe the patient's decision-making ability and understanding of the consequences of their actions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
