Child Psychiatry Consultation

Valmis merkintä

Patient Identification: 13-year-old adolescent presenting with several months of low mood and reduced school participation.

History of Present Illness:
The adolescent reports feeling sad most days for about two months, with lower energy and difficulty concentrating. Symptoms followed a change in peer relationships and have affected homework completion. A caregiver confirms increased time alone. No prior psychiatric treatment.

Past Psychiatric History:
- No prior diagnoses, hospitalizations, self-harm, or aggression reported

Past Medical History:
- No significant medical or surgical history reported
- Development and birth history not discussed

Medications:
- None reported

Allergies:
- No known drug allergies reported

Family Psychiatric History:
- Not discussed

Social History:
- Lives with caregiver
- School attendance continues; recent academic difficulty
- Has one supportive friend
- Substance use and legal history not discussed

Mental Status Examination:
- Calm and appropriately engaged
- Mood described as “down”; affect constricted
- Speech and thought process coherent
- No perceptual disturbance reported
- Alert, insight and judgment age appropriate
- Denies suicidal thoughts, self-harm, or intent to harm others

Physical Examination:
- Vitals not obtained
- No acute physical concern observed

Investigations:

Assessment & Plan:
adolescent with low mood and functional change, symptoms consistent with a depressive syndrome; further assessment is needed.

1) Low mood
- Complete symptom and safety monitoring with caregiver involvement.
- Recommend psychotherapy and regular sleep, activity, and school routines.
- Coordinate supports with school with family consent.
- Follow up soon to reassess symptoms and safety; seek urgent help for suicidal thoughts or rapidly worsening behavior.

Havainnollistava tapaus, jossa potilastiedot ovat keksittyjä. Tämä ei ole oikea potilasasiakirja eikä kliinistä ohjeistusta. Tarkista jokainen merkintä oman vastaanottosi perusteella.

Merkinnän taustalla olevat kliiniset faktat

Uudelleen käytettävä pohjarakenne

Child and Adolescent Psychiatry Consult Note

Patient Identification: [Patient name, age, gender, with a history of..., presenting with...]

History of Present Illness:
[Presenting psychiatric symptoms, onset, duration, severity, and impact on functioning]
[Relevant stressors, precipitating events, and context]
[Previous psychiatric history, treatments, and response]
[Collateral information from caregivers, teachers, or other sources]

Past Psychiatric History:
(hyphenated list)
- [Previous diagnoses]
- [Prior hospitalizations]
- [Past treatments and response]
- [Suicidal or self-harm history]
- [Aggression or violence history]

Past Medical History:
(hyphenated list)
- [Medical diagnoses]
- [Surgical history]
- [Developmental history]
- [Perinatal history]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- (e.g., Fluoxetine 10 mg oral daily)

Allergies:
(hyphenated list)
- [eg. No known drug allergies (NKDA)]

Family Psychiatric History:
(hyphenated list)
- [Relative: Psychiatric diagnosis or relevant history]
- (e.g., Mother: Major depressive disorder)

Social History:
(hyphenated list)
- [Living situation: who lives with patient, home environment]
- [School: grade, performance, attendance, supports]
- [Peer relationships: friendships, bullying, social supports]
- [Extracurricular activities]
- [Tobacco, alcohol, substance use: type, amount, frequency]
- [Legal involvement]

Mental Status Examination:
(hyphenated list)
- [Appearance and behavior]
- [Mood and affect]
- [Speech and language]
- [Thought process and content]
- [Perceptual disturbances]
- [Cognition]
- [Insight and judgment]
- [Risk assessment: suicidal ideation, self-harm, aggression]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [Relevant physical exam findings]

Investigations:
(hyphenated list)
- [Investigation results with units] (Only include completed investigations, otherwise leave blank. All planned or ordered investigations should be included under Plan)

Assessment & Plan:
[One-sentence patient summary including age, sex, and primary psychiatric diagnosis]

#) [Assessment as a numbered item if multiple diagnoses or issues]
(hyphenated list with each corresponding plan item on a new line)
- [Investigations planned or ordered]
- [Pharmacological treatment plan]
- [Psychotherapy or behavioral interventions]
- [Family or school interventions]
- [Safety planning]
- [Referrals sent]
- [Follow up plan]
- [Return precautions]