Client History Report Draft

Client History Report Draft

Your Name (First M. Last)

Psychology

Instructor’s Name

Date submitted

School or Institution Name (University at Place or Town, State)

Client History Report Draft

Identifying information 

Patient’s name is Mr Jones who is righted handed male, of age 44. He is Roman Catholic, Italian American. His is married with wife aged 30 and two kids of age 12 and 15. He has a PhD in English. And is working in Catholic college from 30 years. He is also member of institutional board and reviews 20 grant applications each month. He is full time working men, but when he finds spare time, he likes to do fishing, tinkering cars and rebuilding motors. . He is also proud of his three publications. He has a dynamic personality. He is a family oriented man. His mother died of cancer, Father is alive, and one of his brothers died of colon cancer.

Reason for referral 

He is referred by the neurologist for the neuropsychological evaluation based on thinking and memory changes he is facing after his car accident.

Interact more.

This neuropsychological evaluation will be done to measure cognitive strengths, weaknesses and examine his cognitive and behavioural functioning. This evaluation will reveal the health of his brain and reveal the strength of his abilities related to thinking, motor functioning and memory. The results will be used to evaluate the causes of his difficulties.

Current Symptoms/Presenting Concerns

Mr Jones reports that he was conscious during and after the accident, but he has vague memories of the events that occurred after the accident. He also reports remembering driving back home and then attending the soccer game; he doesn’t have any memories of the accident.

His wife also confirms this event and states that he was unusually quiet and socially withdrawn after the accident. According to him his reports of visiting the MD doesn’t report any spinal and brain injuries.

He has experience with a similar sort of accident in his teenage in which his one friend died. He even received psychotherapy after the incident. He reports mild cases of depression that he thinks are not linked to the accident. He never had any suicidal thoughts. His depression triggered last time when he met his old friends who survived the accident.

He reports having trouble in full filling his occupational duties after the accident. Like in creating new lectures. He also forgets what and how many application he has read. He also reports of an accident when he forgot meeting one of his student in a class. He is also having sleeping problems. He is also recommended by the administration after noticing his changed behaviour that he needs to increase his interaction with his students more. He was always liked by his students and is famous for his exceptional teaching, but recent changes are making things difficult for him.

According to him, his cognitive symptoms have improved after one week of the accident, but he can’t think clearly after it, and his thinking seems fuzzy. His attention span has also reduced, and he finds it hard to keep track of his thoughts and tasks.

He has a family history of neurological disorder. He also bumped his head in his childhood on the cement floor. , and has a small loss of consciousness butt everything normal afterwards.

After evaluation the results of the assessment, it seems like the accident has triggered his symptoms of the underlying neurological disorder. He might be at the start of developing the neurological disorder as his memory and thinking have started to get affected. His learning trials, interfacing trails, recall delays are lower than they should be. This point to some underlying problem ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"3HF3bJwh","properties":{"formattedCitation":"(Arlt, 2013)","plainCitation":"(Arlt, 2013)","noteIndex":0},"citationItems":[{"id":1632,"uris":["http://zotero.org/users/local/KZl8ZL3A/items/NQD3WBQB"],"uri":["http://zotero.org/users/local/KZl8ZL3A/items/NQD3WBQB"],"itemData":{"id":1632,"type":"article-journal","title":"Non-Alzheimer's disease—related memory impairment and dementia","container-title":"Dialogues in Clinical Neuroscience","page":"465-473","volume":"15","issue":"4","source":"PubMed Central","abstract":"Although Alzheimer's disease (AD) is a common cause of memory impairment and dementia in the elderly disturbed memory function is a widespread subjective and/or objective symptom in a variety of medical conditions. The early detection and correct distinction of AD from non-AD memory impairment is critically important to detect possibly treatable and reversible underlying causes. In the context of clinical research, it is crucial to correctly distinguish between AD or non-AD memory impairment in order to build homogenous study populations for the assessment of new therapeutic possibilities. The distinction of AD from non-AD memory impairment may be difficult, especially in mildly affected patients, due to an overlap of clinical symptoms and biomarker alterations between AD and certain non-AD conditions. This review aims to describe recent aspects of the differential diagnosis of AD and non-AD related memory impairment and how these may be considered in the presence of memory deficits.","ISSN":"1294-8322","note":"PMID: 24459413\nPMCID: PMC3898684","journalAbbreviation":"Dialogues Clin Neurosci","author":[{"family":"Arlt","given":"Sönke"}],"issued":{"date-parts":[["2013",12]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Arlt, 2013). But considering the fact, Mr. Jones recalls that his tests were clear on his visit to MD, can’t find correct as he can give wrong information regarding the reports considering his memory and blurry thoughts. Looking at his history it seems like issue can be more associated to the accident that brought memories of his dead friend ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"sPMTWK7S","properties":{"formattedCitation":"(\\uc0\\u8220{}Memory Complaint and Impairment in the Aged: The Effect of Depression and Altered Brain Function | JAMA Psychiatry | JAMA Network,\\uc0\\u8221{} n.d.)","plainCitation":"(“Memory Complaint and Impairment in the Aged: The Effect of Depression and Altered Brain Function | JAMA Psychiatry | JAMA Network,” n.d.)","noteIndex":0},"citationItems":[{"id":1628,"uris":["http://zotero.org/users/local/KZl8ZL3A/items/EE4M2636"],"uri":["http://zotero.org/users/local/KZl8ZL3A/items/EE4M2636"],"itemData":{"id":1628,"type":"webpage","title":"Memory Complaint and Impairment in the Aged: The Effect of Depression and Altered Brain Function | JAMA Psychiatry | JAMA Network","URL":"https://jamanetwork.com/journals/jamapsychiatry/article-abstract/491468","accessed":{"date-parts":[["2019",3,22]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (“Memory Complaint and Impairment in the Aged: The Effect of Depression and Altered Brain Function | JAMA Psychiatry | JAMA Network,” n.d.).

IV. Psychosocial History (complete each of the sections below based on the information in the case you selected)

Educational history:

He has done a PhD in English and has three publications.

Occupational history:

He is teaching in a Catholic college from 30 years. He is like by his students. He is also a member of the institution review board.

Medical history:

No history of drug abuse or heavy abuse. But he drinks one glass of wine each night.

Psychiatric history

He received psychotherapy after the accident in his teenage.

Social history

He is very engaged in his family and extended family. His students and mates always liked him. He always had friends and likes to attend the reunions. He also visits the church that other members of his family also attend.

References

ADDIN ZOTERO_BIBL {"uncited":[],"omitted":[],"custom":[]} CSL_BIBLIOGRAPHY Arlt, S. (2013). Non-Alzheimer’s disease-related memory impairment and dementia. Dialogues in Clinical Neuroscience, 15(4), 465–473.

Memory Complaint and Impairment in the Aged: The Effect of Depression and Altered Brain Function | JAMA Psychiatry | JAMA Network. (n.d.). Retrieved March 22, 2019, from https://jamanetwork.com/journals/jamapsychiatry/article-abstract/491468