Week 10 : Neurocognitive and Neurodevelopmental Disorders, Training title 50

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Faculty Name

Assignment Due Date

 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

Video: Training title 50

Subjective:

CC (chief complaint): “I work at this large architectural engineering firm and they’ve
accelerated the deadlines now and it just puts a lot of pressure on and I just can’t
concentrate.

HPI: H.B. is a 60-year-old male Caucasian patient who comes for evaluation because
he was having difficuly concentrating at work. His supervisor therefore booked this
appointment for him. He is currently on Cozaar 100mg daily for hypertension, ASA
81mg orally daily for angina, valsartan 80mg daily, fenofibrate 160mg orally daily for
hypertriglyceridemia, and tamsulosin 0.4mg orally at bedtime for benign prostate
hyperplasia. He presents for evaluation because he has difficulty concentrating at work.
This followed after there was an acceleration of deadlines and this has put a lot of
pressure on him and can’t seem to be able to do the same job that others are doing. He
reports that the firm wanted him to design ari ducts but he designed them through solid
wall, a fire wall, and a supporting wall and he did not even realise what he was doing.
He reports that he keeps making silly mistakes at work. He also reports that he
designed the windows openings way to small and if this design was to go ahead, it
would have cost millions. He reports that these problems started when the deadlines
were accelerated. He also reports that he had similar problems at school particularly
when studying for exams. He reports that whenever he went to the library, he ended up
looking out the window instead of concentrating on his studies. He also reports that if
anyone was whispering in the library, he had to go to the other side as he could not
concentrate. However, his friends could study anywhere. He also reports that he does
not concentrate whenever they are having lectures from their chief of the department.
He also admits that he has problems organizing. He is a bit messy as he can at times
not find his shoes, socks, phone, and jacket as he is not that organized. One of his
coworkers actually bought him a calender to motivate him. He would write down all the
important dates and events but he does not ever look at that calender. He also keeps
forgetting to pay his bills. He pays them after a few threatening calls and letters, after
which he pays the penalties incurred. He also reports that at times he is a bit
uncomfortable in a chair but does not consider that a big deal. He has no history of
medications or behavioral therapies for ADHD. Patient takes coffee and soda once in a
while. He however does not take sugar.

Past Psychiatric History:

 General Statement: Patient has never been evaluated for ADHD before.
However, his mother once threatened to drag him into a doctor’s office when he
was a kid.
 Caregivers (if applicable): He lives alone since he is not married and has no
children.
 Hospitalizations: Patient has no previous psychiatric hospitalizations.

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 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

 Medication trials: Patient has not been put on any psychiatric medications.
 Psychotherapy or Previous Psychiatric Diagnosis: The patient has not undergone
any psychotherapy before and has not been diagnosed with any psychiatric
illness.

Substance Current Use and History: Patient denies history of drug use. He however
enjoys 1 scotch drink on the weekends with a cigar. Patient also takes coffee and soda
once in a while.

Family Psychiatric/Substance Use History: Patient has no significant family

psychiatric and substance use history.

Psychosocial History: The patient is a 60-years-old Caucasian male. Patient has a

bachelor’s degree in engineering. He dates casually. He is not married and has no
children. He has a younger brother. He sleeps for 7 hours. He denies any legal issues.

Medical History: Patient has a history of hypertension controlled with Cozaar 100mg
daily. He also has hypertriglyceridemia, angina, and benign prostate hyperplasia.

 Current Medications: Patient is currently on Cozaar 100mg daily for

management of hypertension, ASA 81mg orally daily for angina, and valsartan
80mg daily. He is also on fenofibrate 160mg daily for hypertriglyceridemia, and
tamsulosin 0.4mg orally at bedtime for benign prostate hyperplasia.
 Allergies: Patient is allergic to Dilaudid.
 Reproductive Hx: Patient currently dates casually and has no children.

ROS:

 GENERAL: The patient denies having fevers, rigors, body weakness and fatigue.
He sleeps for 7 hours and his appetite is good.
 HEENT: Patient has no blurred vision, double vision, or yellow sclerae. He
however wears glasses as he is short-sighted. Ears, Nose,Throat: No hearing
loss, sneezing, congestion, runny nose, or sore throat.
 SKIN: No rash or itching
 CARDIOVASCULAR: Patient has a history of angina pains. He also has
hypertension which is managed by the drugs mentioned previously. Patient
however has no palpitations and no edema.
 RESPIRATORY: No shortness of breath, cough, or sputum.
 GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No
abdominal pain or blood.
 GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color
 NEUROLOGICAL: Patient has difficulty concentrating. He is also forgetful. He
has no headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in
the extremities. No change in bowel or bladder control.

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 MUSCULOSKELETAL: Patient has no muscle, back pain, joint pain, or stiffness.

 HEMATOLOGIC: No anemia, bleeding, or bruising.

 All other systems are unremarkable.

Objective:

Vitals: T- 98.8 P- 74 R 18 134/70 Ht 5’10 Wt 170lbs

Physical exam: On examination, the patient is an elderly Caucasian male patient. He is

in a fair general condition and is of good nutritional status. He is well oriented to time,
place, event, and person. He dressing is congruent with the time of the year and
weather. He has a pair of glasses. His memory is intact as he can even remember
about his childhood events. He fidgets once in a while and uses gestures when
communicating. He appears anxious.

Diagnostic results: The patient has undergone the Montreal Cognitive Assessment
(MOCA) test and scored 28/30. He is an appropriate candidate for this as he is quite
forgetful at work and has difficulty concentrating. He has also undergone the ADHD self-
report screening scale (ASRS-5) and scored 21/24. A cognitive test called the Montreal
Cognitive Assessment (MoCA) was created to identify dementia and mild cognitive
impairment. Its psychometric superiority to other screening tools has been shown in
numerous research. The MoCA provides an estimate of global cognition rather than a
thorough assessment of cognition, aiding physicians in determining whether to refer
patients for neuropsychological testing. The MoCA has been shown to be useful across
a wide range of neurologic populations by research.

Assessment:

Mental Status Examination: The patient is a 60-year-old male patient. He is awake,

alert, and well oriented to time, place, person, and event. He has no gross
abnormalities. He is well dressed and groomed. He appears to be of the stated age. His
mood appears to be anxious, and his affect is congruent with his mood. His speech is
coherent and audible. His thought processes are linear and goal oriented. He denies
both auditory and visual hallucinations. Based on his vocabulary, his cognitive function
is intact and age appropriate. His concentration during the interview is fair, and his
judgment seems to be clouded by his symptoms.

Differential Diagnoses:
a) Attention Deficit/Hyperactivity Disorder (ADHD) - The ability of children to
function is impacted by Attention Deficit-Hyperactivity Disorder (ADHD), a mental
illness. People with this illness exhibit tendencies of inattentiveness,
hyperactivity, or impulsivity at levels that are developmentally inappropriate. The
DSM IV unified Attention Deficit Disorder and Attention Deficit Hyperactivity
Disorder into a single disorder with three subtypes: primarily inattentive, mainly
hyperactive, or combination type. Previously, these disorders were diagnosed

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separately. Young children typically exhibit symptoms such as inattentiveness,

lack of concentration, disorganization, difficulty finishing chores, forgetfulness,
and losing items. To qualify as having "ADHD," a person's symptoms must start
before the age of 12, endure for six months, and interfere with daily activities.
This needs to be true across many contexts (i.e., at home and school, or school
and after-school activities). Large-scale repercussions may include problematic
social interactions, a rise in risky conduct, job losses, and difficulties in the
classroom (Sayal et al., 2018). DSM-5 diagnostic criteria for ADHD states that
there must be 5 or more signs of inattention. These symptoms must be present
for at least 6 months and must be to a degree that impacts one’s living. These
symptoms must also be persistent in 2 or more areas of the patient’s life
(Chandra et al., 2016). It should be clear how the symptoms affect the patient’s
life e.g. symptoms may interfere with school work, or occupational functioning.
This patient meets all the above criteria. First of all, he does not concentrate well
at work and ends up making mistakes that can cost his firm millions of money.
Also, when he was in school, he could not concentrate in the library whenever
someone was whispering. He does not also concentrate during lectures that are
arranged by the chief of department at his workplace. These symptoms interfere
with his life as they have made him make serious mistakes at workplace. This is
risky as it could cost him his job. He also keeps forgetting to pay his bills and
pays them after receiving threatening calls or letters. ADHD is therefore my main
diagnosis for this patient.
b) Generalized anxiety disorder - The most often occurring mental illness is
generalized anxiety disorder. Every year, anxiety disorders affect up to 20% of
adults. Generalized anxiety disorder is characterized by fear, worry, and a
recurring sense of being in control (DeMartini et al., 2019). Generalized anxiety
disorder is characterized by excessive, illogical, and ongoing worry over
everyday events. Numerous topics, including money, family, health, and the
future, may be the focus of this concern. It is overly intense, difficult to control,
and typically accompanied by a wide range of hazy psychological and physical
symptoms. Excessive concern is a defining feature of generalized anxiety
disorder. The DSM-5 criteria for diagnosis of GAD include worry and anxiety
occurring for at least 6 months, about a number of events or activities such as
work or school performance, difficulty controlling this worry, the disturbance is not
better explained by another mental disorder, and the disturbance is not
attributable to the physiological effects of substance use (Angulo et al., 2017).
This patient meets the criteria for GAD because he has difficulty concentrating at
work and this is making him worried since others are able to do their job well
even after acceleration of the deadlines. He also has difficulty listening. However,
I ruled this diagnosis out because the patient does not experience any anxiety or
fear.He has no symptoms associated with anxiety such as sweating and
palpitations.
c) Major depressive disorder – According to DSM-5, major depressive disorder is
diagnosed when a patient has persistently depressed mood, decreased interest
in pleasurable activities, feelings of guilt, lack of energy, poor concentration,
appetite changes, agitations, sleep disturbances, or suicidal thoughts (Kaser &

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Sahakian, 2019). A patient must have at least 5 of the mentioned symptoms to

be diagnosed with major depressive disorder. However, in this case, the patient
only experiences one of the stated symptoms which is poor concentration. As
stated, his appetite is good and he sleeps for 7 hours. This does not indicate any
appetite changes or sleep disturbances. I therefore rule this out as my diagnosis.

Reflections: This was a straight forward case. I quickly concluded that the patient was
suffering from ADHD. If I was to conduct this session once again, I would inquire more
about how the patient feels about his work. I would also want to know his close friends
and talk to them so as to know whether they have noticed any changes about the
patient. This would enable me to know whether he has any social support. This would
also reflect how his stress at work is affecting his social life. I would also inquire more
about his lifestyle i.e. his diet and whether he is physically active. This is because
physical activity may aid in the management of some psychiatric symptoms such as
anxiety and depression. In terms of legal and ethical issues, I would ensure that I obtain
informed consent before performing any examination on the client. It would also be
important to brief the patient on your examination findings. The patient should also have
a right to take part in his treatment. He has a right to accept or decline treatment. It is
however important to advice the patient on the essence of medication compliance.
Information obtained from the patient should also not be shared to unauthorized parties
without the patient’s permission.

References

Angulo, M., Rooks, B. T., Gill, M., Goldstein, T., Sakolsky, D., Goldstein, B., Monk, K.,

Hickey, M. B., Diler, R. S., Hafeman, D., Merranko, J., Axelson, D., & Birmaher, B.

(2017). Psychometrics of the screen for adult anxiety related disorders (scaared)- A

new scale for the assessment of DSM-5 anxiety disorders. Psychiatry Research, 253,

84-90. https://doi.org/10.1016/j.psychres.2017.02.034

Chandra, S., Biederman, J., & Faraone, S. V. (2016). Assessing the validity of the age at

onset criterion for diagnosing ADHD in dsm-5. Journal of Attention Disorders, 25(2),

143-153. https://doi.org/10.1177/1087054716629717

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of

Internal Medicine, 170(7), ITC49. https://doi.org/10.7326/aitc201904020

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Kaser, M., & Sahakian, B. J. (2019). Major depressive disorder as a disorder of cognition.

Cognitive Dimensions of Major Depressive Disorder, 23-34.

https://doi.org/10.1093/med/9780198810940.003.0003

Sayal, K., Prasad, V., Daley, D., Ford, T., & Coghill, D. (2018). ADHD in children and

young people: Prevalence, care pathways, and service provision. The Lancet

Psychiatry, 5(2), 175-186. https://doi.org/10.1016/s2215-0366(17)30167-0

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