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_01-00_nse.qmd
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_01-00_nse.qmd
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# NEUROBEHAVIORAL STATUS EXAM {#sec-nse}
## Reason for Referral
<!-- Information to Include in Reason for Referral Section
• List name and position of referral source
• Reason the individual is to be evaluated—What questions are to be addressed?
• Concerns of parent, caregiver, teacher, or examinee (if applicable)
• Previous diagnoses, disabilities, or medical concerns -->
{{< var first_name >}} {{< var last_name >}} is a {{< var age >}}-year-old, {{< var handedness >}}right-handed research assistant with {{< var education >}} years of education, including a B.A. in Hustling from the University of Bed-Sty. {{< var he_she_cap >}} was referred in order to determine the nature and extent of neurocognitive sequelae emerging from a history of attention-deficit/hyperactivity disorder (ADHD).
The purpose of the current evaluation is {{< var dx1 >}}, {{< var dx2 >}}, and {{< var dx3 >}}. This report is based on a review of available medical records and information gathered across multiple days of evaluation. Treatment planning and plans for test accommodations were discussed with {{< var first_name >}} during the feedback visit on the final day of the examination.
## Background
<!-- **Information to Include in Background Information Section**
Provide pertinent information that has been obtained from all sources, including the referral source, family members, examinee, teachers, medical records, and so on. Do not include needless details or gossip. Following are examples of information that should be included:
• Current family dynamics (spouse, children, siblings, etc.)
• Medical and psychiatric history
• Developmental history
• Educational history (note any special services)
• Employment history (for adults)
• Previous therapeutic intervention
• Current stressors
• Summary of past evaluations -->
The following information was obtained during an interview with {{< var patient >}} and from review of available medical records. {{< var first_name >}} has been doing well in {{< var his_her >}} classes since starting law school and has never failed. However, issues have begun to arise that {{< var he_she >}} has been unable to avoid, including being easily distracted, restlessness, constantly fidgeting, procrastination, and variable attention. {{< var he_she_cap >}} suspects having ADHD and has always struggled with aspects of it. {{< var first_name >}}'s mother tried to get {{< var his_her >}} evaluated and tested when {{< var he_she >}} was younger, but was never able to do so because {{< var his_her >}} school at the time did not agree that there were major concerns. {{< var he_she_cap >}} has noticed increasing difficulty initiating tasks, especially when it comes to writing long research papers, and has been procrastinating more and more. {{< var first_name >}} has read up on ADHD and believes {{< var he_she >}} may have it, but has been able to hide it from others, as {{< var he_she >}} has "gotten good at pretending to pay attention." {{< var he_she_cap >}} seeks further assessment and evaluation to identify any underlying neurocognitive factors influencing {{< var his_her >}} academic motivations and performance.
**Cognitive complaints**: sustained attention, working memory, and organization.
## Relevant History
### Past Neuropsychological Test Results
Patient denied having prior testing.
### Birth/Early Development
- Normal pregnancy, birth, and delivery.
- Developmental milestones achieved on time.
### Medical History
::: {.block above="1.2em"}
- **Current**: Consequat ad est amet deserunt dolor amet cillum nisi irure sit consequat officia do..
- **Family**: Irure anim qui deserunt eu culpa aliqua ea consequat deserunt..
- **Medications**: None.
- **Appetite/Weight**: Stable with no significant changes recently.
- **Sleep**: Normal, no changes.
- **Neurological Injury**: Voluptate magna do id veniam id laborum in qui magna sint ad cillum commodo.
- **Psychiatric**: ADHD, anxiety, and depression.
:::
### Behavioral/Emotional/Social
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### Educational History
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### Occupational History
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### Cultural/Social Context
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