Week 10: Assessing and Diagnosing Patients With Neurocognitive and Neurodevelopmental Disorders.
College of Nursing-PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
CC (chief complaint): “ I have problem with concentration, I just can’t concentrate”.
HPI: H.G is a 58 years old male patient that came in due to his concentration problem. He informed his supervisor who set up the appointment. His concentration got worse when his job raise the deadlines, and he could not meet up with it. He constantly makes mistake that could cause millions of money at work. He mentioned that his concentration is been affecting him since his time in school. He has problem organizing at home and at work. His concetration problem affects his bills due date because he usually forgets to pay for it. He is usually hyperactive, does not seat one place or stay focus. He denies any legal issues. Montreal Cognitive Assessment (MOCA) 27/30 difficulty with attention and delayed recall; ASRS-5 20/24. He sleeps 4-6 hours at night, and has a good appetite.
Past Psychiatric History:
- General Statemen: Patient came in due to his problrm with concentration and focus. His mind usually skips to many things at work, which made his supervisor referred him for help.
- Caregivers: Self
- Hospitalizations: None
- Medication trials: N/A
- Psychotherapy or Previous Psychiatric Diagnosis: Never treated or evaluated.
Substance Current Use and History: He denies drug use. Drinks one scotch drink on the weekends with a cigar.
Family Psychiatric/Substance Use History: N/A
Psychosocial History: Patient has baschalor degree in Engineering. He works at a large architectural Enginering firm. He has one younger sister. He was raised by his mother.
Medical History: Hypertension, Hypertriglyceridemia, Angina, and BPH.
- Current Medications: Losartan 100mg daily, ASA 81mg po daily, Metoprolol 25mg twice daily, Fenofibrate 160mg daily, Tamsulosin 0.4mg po bedtime.
- Allergies: Morphine
- Reproductive Hx: He is homosexual and dates casually, never married, no children.
- ROS:
- GENERAL: Patient reports good appetite.
- PSYCHITRIC: Patient reports memory and concentration problem.
- Physical exam:
HEENT:No head trauma, norcephalic, Conjunctive are normal, No hearing problem, No nose bleed or any discharge from the nose noted.
Skin: No skin rashes noted.
Psychiatric: Patient remain
General: Patient is alert and oriented. He remained calm and was cooperative throughout the section.
Diagnostic results: Montreal Cognitive Assessment (MOCA) and Adult ADHD Self-Report Screening Scale for DSM-5 (ASRS-5).
Assessment
Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.
He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.
Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.
Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
References
Symptom Media. (Producer). (2017). Training title 50 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-5
Week 10: Assessing and Diagnosing Patients With Neurocognitive and Neurodevelopmental Disorders.
College of Nursing-PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
CC (chief complaint): “ I have a problem with concentration, I just can’t concentrate”.
HPI: H.G is a 58 years old male patient that came in due to his concentration problem. He informed his supervisor who set up the appointment. His concentration got worse when his job raise the deadlines, and he could not meet up with it. He constantly makes a mistake that could cause millions of money at work. He mentioned that his concentration is been affecting him since his time in school. He has a problem organizing at home and work. His concentration problem affects his bills due date because he usually forgets to pay for them. He is usually hyperactive and does not seat one place or stay focused. He denies any legal issues. Montreal Cognitive Assessment (MOCA) 27/30 difficulty with attention and delayed recall; ASRS-5 20/24. He sleeps 4-6 hours at night and has a good appetite.
Past Psychiatric History:
- General Statement: The patient came in due to his problem with concentration and focus. His mind usually skips too many things at work, which made his supervisor referred him for help.
- Caregivers: Self
- Hospitalizations: None
- Medication trials: N/A
- Psychotherapy or Previous Psychiatric Diagnosis: Never treated or evaluated.
Substance Current Use and History: He denies drug use. Drinks one scotch drink on the weekends with a cigar.
Family Psychiatric/Substance Use History: N/A
Psychosocial History: The patient has a Bachelor degree in Engineering. He works at a large architectural Engineering firm. He has one younger sister. He was raised by his mother.
Medical History: Hypertension, Hypertriglyceridemia, Angina, and BPH.
- Current Medications: Losartan 100mg daily, ASA 81mg po daily, Metoprolol 25mg twice daily, Fenofibrate 160mg daily, Tamsulosin 0.4mg po bedtime.
- Allergies: Morphine
- Reproductive Hx: He is homosexual and dates casually, never married, no children.
- ROS:
- GENERAL: The patient reports a good appetite.
- PSYCHIATRIC: The patient reports memory and concentration problem.
- Physical exam:
HEENT:No head trauma, norcephalic, Conjunctive are normal, No hearing problem, No nose bleed or any discharge from the nose noted.
Skin: No skin rashes noted.
Psychiatric: Patient remain
General: Patient is alert and oriented. He remained calm and was cooperative throughout the section.
Diagnostic results: Montreal Cognitive Assessment (MOCA) and Adult ADHD Self-Report Screening Scale for DSM-5 (ASRS-5).
Assessment
Mental Status Examination:
The 58-year-old patient appears like his stated age. He is well dressed for the weather and occasion. He is oriented to time and place. He has a clear, logical, and coherent speech. The patient has no tics and uses appropriate gestures and facial expressions. The patient however appears anxious during the interview as he keeps tapping his fingers on his thighs. The patient also is fidgeting during the interview. He denies hallucinations or suicidal ideations.
Differential Diagnoses:
Based on the patient’s clinical manifestation, the differential diagnoses would be attention deficit and hyperactivity disorder, generalized anxiety disorder, and an autism spectrum disorder.
Attention deficit and hyperactivity disorder (ADHD)
Attention deficit and hyperactivity disorder are the primary differential diagnosis based on the patient’s signs and symptoms. According to the DSM-5 criteria, people with ADHD show a consistent pattern of either inattention or hyperactivity-impulsivity which interfere with development and daily functioning (Keilow et al., 2018). Adults should show five or more symptoms of inattention which should be present for at least six months. The symptoms of inattention include the inability to give close attention to details, trouble paying attention when handling tasks, trouble organizing tasks and activities, forgetfulness, and being easily distracted. The patient shows some symptoms of hyperactivity such as fidgeting, tapping his hands and feet, squirming on the seat, does not sit still in one place, and talks excessively. In addition, the patient’s history indicates that his concentration problem has been affecting him since his time in school which shows it has lasted up to adulthood.
Generalized anxiety disorder
The second differential diagnosis is a generalized anxiety disorder. The DSM-5 diagnostic criteria require that for patients to be diagnosed with the condition, they must show at least three or more of the following symptoms. The symptoms include restlessness, difficulty concentrating, being easily fatigued, sleep disturbances, irritability, and muscle tension (Patriquin & Mathew, 2017). During the interview, the patient indicates that the tight deadlines at his place of work have made his situation worse resulting in mistakes that could cost his workplace millions.
Autism Spectrum Disorder
The DSM-5 diagnostic criteria for autism spectrum disorder is the prevalence of deficits in three areas of social communication and interaction. A patient should demonstrate deficits in social-emotional reciprocity, deficits in non-verbal communication, inability in maintaining relationships, hyperactivity, highly restricted and fixated interests, insistence on sameness, and repetitive movements (American Psychiatric Association, 2013). The patient has been having concentration issues since his school days, during the interview, he demonstrated repetitive movements on his body as well as deficits in non-verbal communication.
Reflect notes:
If I were to conduct the session again with the patient, I would engage the patient in some relaxation techniques such as deep and regulated breathing which would make the patient relax and minimize fidgeting and tapping which are likely to be associated with anxiety.
I would encourage the patient to participate in physical activity which is a health promotional practice that would enable him to deal with his restlessness, concentration, and anxiety symptoms. More so, the exercise would help him achieve positive health outcomes related to his chronic illnesses.
Legal and Ethical Issues
An ethical issue that would arise when caring for this patient would relate to his safety based on the several medications that he has been put on to manage his conditions. It would be of paramount significance to look into possible drug interactions to minimize adverse events.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Keilow, M., Holm, A., & Fallesen, P. (2018). Medical treatment of Attention Deficit/Hyperactivity Disorder (ADHD) and children’s academic performance. PloS one, 13(11), e0207905.
Patriquin, M. A., & Mathew, S. J. (2017). The neurobiological mechanisms of generalized anxiety disorder and chronic stress. Chronic Stress, 1, 2470547017703993.
Symptom Media. (Producer). (2017). Training title 50 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-5