Introduction: Give a description of the person & the presenting problem include objective data and subjective if applicable. You might have to state the presenting problem in terms of what you see as the person’s main dysfunction currently or during their lifetime. Background: include any pertinent information about the
person’s past. Some items will not be able to be included, for example, current physical examination results would not be possible, however, a brief over view of the person’s medical issues and background would be more appropriate. Be sure to include a description and examples of the person’s current level of functioning. If a person is no longer alive, describe the over riding problem and level of dysfunction over their lifetime.
1.Give the person a DSM-IV-TR or DSM 5 diagnosis and the rationale for your assertions.
2. List and discuss treatment options for this person and why those would be your treatment(s) of choice.
3. Give a prognosis, including both potential obstacles to treatment, as well as what about the patient or her life situation that could serve as strengths in the treatment process.