Week (10 ): (Title 50, Assessing and Diagnosing Patients With Neurocognitive andNeurodevelopmental Disorders

Week (10 ): (Title 50, Assessing and Diagnosing Patients With Neurocognitive andNeurodevelopmental Disorders

Subjective:

Personal details: Harold Brown a 60-year-old Caucasian male

CC (chief complaint): Patient visits the clinic for psychiatry review at the request of his

supervisor after experiencing difficulty in concentration while carrying out his daily routine

duties

HPI: Mr. HB, is a 60-year-old Caucasian male who comes for a psychiatry review evaluation at

the request of his supervisor after experiencing difficulty in concentration while carrying out his

daily duties. He is an engineer at a large architectural engineering firm whose concentration has

gotten worse since his company accelerated the deadlines of the designated tasks. Unlike every

other employee who can cope with the new directives, he reports that this has added a lot of

pressure on him and he cants just concentrate and seems not to have the ability to do the same

job others are doing. He reports having been making very silly mistakes that he would have not

done before. For instance, He mis designed simple air ducts and even the window opening of a

whole building which would have cost the firm a lot. He reported to have not had these

concentration difficulties in the workplace when things were relaxed and deadlines were normal.

However, while in high school he had some difficulties with attention and ended up gazing out

through the window instead of reading for exams while at the library. Inside the library, he was

also not able to tolerate even whispers and had to move to other quiet places. He also experiences

these attention difficulties whenever attending group lectures where his mind is always away on

personal thoughts while other people are trying to work out the group goals. He also thinks he is

in a mess after misplacing personal items such as shoes, socks, his phone, or even his jacket

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

also forgets to clear the bills and ends up penalized for late payments. He has never been treated

for ADHD before, and takes caffeine drugs such as coffee and soda but doesn't take sugar.

Past Psychiatric History:

General Statement: The patient has never been assessed or treated for ADHD before but

her mother once threatened to drag him to the hospital but she didn’t do it

Caregivers (if applicable): Lives alone as he had never married

Hospitalizations: He has no previous psychiatry admissions

Medication trials: he has not been on any psychiatry medication trials

Psychotherapy or Previous Psychiatric Diagnosis: The patient has not attended any

psychotherapy in the past and has not been diagnosed with any psychiatric disorders

Substance Current Use and History: Harold consumes caffeine daily in the form of coffee and

soda. He occasionally drinks alcohol, typically one scotch accompanied by a cigarette on the

weekends. He has no history of drug use or withdrawal complications.

Family Psychiatric/Substance Use History: The patient has no significant familial significant

history only that her mother threatened to take him for ADHD evaluation but it didn’t go

through.

Psychosocial History: The patient is a 60-year-old male who was born and raised in the United

States. He has one younger brother and was raised by his parents.

and does not have any children. He has a bachelor's degree in engineering and is currently

employed. He has no past or current legal issues.

Medical History: Harold has a history of hypertension, angina, and hypertriglyceridemia. He

has also been diagnosed with BPH and has no significant surgical history. He has no history of

seizures, head injuries, or any other serious illnesses or surgeries.

Current Medications: takes Cozaar 100mg daily for hypertension, takes ASA 81mg PO

daily, and valsartan 80mg daily for angina. Uses fenofibrate for hypertrygliceridemia and

tamsukosin for BPH.

Allergies: He allergic to Dilaudid

Reproductive Hx: He dates casually, has never married, and does not have children

ROS:

GENERAL: Patient denies fever, chills, rigors, malaise, and fatigue. He reports sleeping

an average of 7 hours.

HEENT: He denies head trauma, he wears glasses because of his short-sightedness, and

he denies auditory or balance disturbance. He denies nasal blockage, discharge, or

difficulty in swallowing.

NEUROLOGICAL: The patient has difficulty concentrating and is often forgetful. He

denies feeling dizzy, having headaches, syncope, paralysis, ataxia, numbness, or any