Upon your assessment make a Diagnosis based on DSM-5 and Treatment Plan: Definitive diagnosis, Differential diagnosis: and other Include neurobiology of disorder(s). (Include genetics, neurotransmitters, neuroanatomical changes, current theories of causation, cultural factors);
Rationale for each part of management plan (labs; meds: why this med, what is neurochemistry action of med, side effects to monitor, expected benefits, contraindications; counseling-goals, rationale for this type of therapy, expected benefits, teaching, referrals, follow-up)
I ALWAYS HAD ISSUES IN FOCUS AND CONCENTRATION BUT NOW DECIDED NEED TO TAKE CARE OF IT
HPI: 25 YR OLD S/A/A/F WHO IS EMPLOYED AS SERVER AT RESTAURANT WAS REFERRED BY PCP FOR PSYCHIATRIC EVALUATION FOR ISSUES RELATED TO FOCUS AND CONCENTRATION
PT STATED SHE AWAYS STRUGGLED IN SCHOOL BUT HER FAMILY DID NOT BELIEVE IN MEDS THEY THOUGH SHE COULD WORK SELF AND DO WELL SO WAS NEVER BEEN TREATED SHE BARELY ABLE TO PASS CLASSES
ALWAYS HAD ISSUES WITH DAY DREAMING
NOT COMPLETING TASK GETS DISTRACTED EAISLY
HARD TO SIT STILL ALWAYS HAS TO MOVE AROUND
HAS LOT OF UNFINISHED WORK
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Upon your assessment make a Diagnosis based on DSM-5 and Treatment Plan: Definitive diagnosis, Differential diagnosis: and other Include neurobiology of disorder(s). (Include genetics, neurotransmitters, neuroanatomical changes, current theories of causation, cultural factors); Rationale for each part of management plan (labs; meds: why this med, what is neurochemistry action of med, side effects to monitor, expected benefits, contraindications; counseling-goals, rationale for this type of therapy, expected benefits, teaching, referrals, follow-up)
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BUT NO HX OF IMPULSIVE BEHAVIOR
NO AGITATION
PT WAS SEEN ALONG WITH HER MOM
NO KNOWN PAST MEDICAL HISTORY
Upon your assessment make a Diagnosis based on DSM-5 and Treatment Plan: Definitive diagnosis, Differential diagnosis: and other Include neurobiology of disorder(s). (Include genetics, neurotransmitters, neuroanatomical changes, current theories of causation, cultural factors)
Rationale for each part of management plan (labs; meds: why this med, what is neurochemistry action of med, side effects to monitor, expected benefits, contraindications; counseling-goals, rationale for this type of therapy, expected benefits, teaching, referrals, follow-up).
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Upon your assessment make a Diagnosis based on DSM-5 and Treatment Plan: Definitive diagnosis, Differential diagnosis: and other Include neurobiology of disorder(s). (Include genetics, neurotransmitters, neuroanatomical changes, current theories of causation, cultural factors); Rationale for each part of management plan (labs; meds: why this med, what is neurochemistry action of med, side effects to monitor, expected benefits, contraindications; counseling-goals, rationale for this type of therapy, expected benefits, teaching, referrals, follow-up)
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