Context of consultation:
The consultation took place at the family home on 1 November 2024. Present were the patient, [insert patient name], their parents, and Dr. Thomas Kelly, Pediatric Psychologist.
Domestic and family environment:
Both parents have university degrees. The home environment is well-organised and provides a supportive atmosphere for the patient.
Index Incident:
The patient sustained a head injury in a car accident on [insert date].
Details of the incident and markers of severity:
The patient was a passenger in a car that was involved in a high-speed collision. The patient was unconscious at the scene and was taken to hospital by ambulance. The patient was diagnosed with a moderate traumatic brain injury.
Development prior to the index incident:
The patient met all developmental milestones on time. They were described as a happy and well-adjusted child with good social skills and a love of reading.
Development subsequent to the index incident:
Following the accident, the patient experienced significant difficulties with memory and attention. They also developed emotional lability and increased irritability. The patient has been receiving speech therapy and occupational therapy.
Current Cognitive Functioning:
The patient struggles with everyday tasks that require sustained attention. They have difficulty following multi-step instructions. The patient's language skills remain intact, but they have difficulty with word finding. Memory is impaired, particularly for new information. Executive function skills are impaired, and the patient struggles with planning and organisation.
Behavioural, social and emotional functioning:
The patient exhibits increased irritability and frustration. They have difficulty managing their emotions and often become tearful. Socially, the patient has withdrawn from some of their friends and activities.
Vision, hearing, medical issues and general health:
The patient's vision and hearing are within normal limits. The patient has ongoing headaches and fatigue. The patient is currently taking medication for their headaches.
Seizure history:
The patient has not experienced any seizures.
Injury history:
The patient has a history of head injuries.
Motor function:
The patient's motor function is within normal limits.
General development and school progress:
The patient is currently attending school, but they are struggling academically. They are receiving support from a special education teacher.
Practical understanding of legal issues and finance:
Not applicable.
Future expectations:
The patient's parents are hopeful that the patient will continue to make progress with therapy and support. They are concerned about the long-term impact of the injury on the patient's future.
Consultation and/or observation at home/school:
Not applicable.
Context of consultation:
[describe where and when consultation took place, who was present] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Domestic and family environment:
[describe academic achievements of family members] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe physical setup and organisation of the home environment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Index Incident:
[describe the index incident / accident or brain injury] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe details of the incident and markers of severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Development prior to the index incident:
[describe features of development prior to the incident] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe motor, social, linguistic and temperamental aspects of development] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Development subsequent to the index incident:
[describe features of development following the incident from the immediate aftermath to longer term difficulties] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe motor, social, linguistic and temperamental aspects of development] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Current Cognitive Functioning:
[describe everyday competencies and skills] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe language and communication] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe memory] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe attention] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe executive function and organisational skills] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Behavioural, social and emotional functioning:
[describe behavioural functioning] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe social functioning] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe emotional functioning] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Vision, hearing, medical issues and general health:
[describe vision] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe hearing] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe general health] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe medical issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Seizure history:
[describe seizure history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Injury history:
[describe any head injuries or accidents] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe injury history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Motor function:
[describe motor function] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
General development and school progress:
[describe general development] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe school progress] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Practical understanding of legal issues and finance:
[describe practical understanding of legal issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[describe practical understanding of finance] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Future expectations:
[describe future expectations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Consultation and/or observation at home/school:
[describe consultation and/or observation at school and any observations of behaviour during the session] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section and placeholder above, only include content if it is explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the section entirely. Never hallucinate or infer details. Do not state that information is missing—simply leave out any section or placeholder without explicit supporting information. Use only the transcript, contextual notes, or clinical note as reference for all content. Use as many lines or paragraphs as needed to capture all relevant information.)
