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Neurocognitive Disorder Case Presentation Using SOAP

Neurocognitive Disorder Case Presentation Using SOAP

Case study : dx: moderate intellectual disability, borderline personality disorder, Schizo, affective disorder, with psychosis, pica. medical dx: hypothyroidism, constipation, GER, IBS, myopia, and HTN. HX: JB is 42 y/o Caucasian male presented with his 2 brothers for psychiatric evaluation. he has history of neurocognition disorder due to his intellectual disability from childhood. and has been noncompliant with his medications for at least 3 weeks. he is supposed to be taking clorazepate, Risperdal and aripiprazole. according to the brothers he is seen frequently talking and laughing to himself and sleeping very poorly. prior transfer he leaves at home with his family and they are taking care of him on a rotational schedule with government support due to his disability, it is hard for the family to take care of him due to his noncompliant he was non-functional and unable to work. patient Urine drug screen is negative for benzo and alcohol level <10. patient will be admitted to psych unit for further evaluation.

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