Comprehensive Psychiatric Evaluation – Assessment, Diagnosis, and Clinical Reasoning

Comprehensive Psychiatric Evaluation – Assessment, Diagnosis, and Clinical Reasoning

ID: Name: HG Age: 58 years Gender: Male

Subjective:

CC (chief complaint): “I just can’t concentrate.”

HPI: HG is a 58-year-old male presenting with complaints of difficulty concentrating. This problem began after the acceleration of task completion deadlines at his workplace. He seems to be the only one having the problem, as others have not reported similar complaints. His difficulty concentrating seems to be affecting his professional work as he keeps making mistakes. He noted that the problem with difficulty in concentration has been around for some time, as he had had a similar experience during his school days. He misses small details when executing his tasks, something he reports may cost the company millions of cash. He also seems not to listen when he and other organizational members are being lectured. HG also has a problem completing tasks and meeting deadlines. He is also forgetful and disorganized. He is also hyperactive.

Past Psychiatric History:

General Statement: No reports of any past psychiatric illness.

Hospitalizations: No reports of any past hospitalization due to mental health illnesses or somatic illnesses. There were also no reports of head injuries or surgeries.

Medication trials: No reports of medication trials.

Psychotherapy or Previous Psychiatric Diagnosis: No reports of previous psychiatric diagnosis.

Substance Current Use and History: HG enjoys one scotch drink and a cigar. He, however, denies having a history of drug use.

Family Psychiatric/Substance Use History: No reports of mental health illnesses in the family. There is also no report of substance use within the family.

Psychosocial History: HG is a homosexual. He dates casually and has never married. He has no children but has one younger sister. He has a bachelor’s degree in engineering and works in an architectural engineering firm. He has no history of legal issues.

Diet and Sleep: HG sleeps 4-6 hours. His appetite is good. He occasionally takes coffee.

Medical History:

• Medical problems list: HG is hypertensive. He also has angina, BPH, and hypertriglyceridemia.
• Current Medications: Losartan 100mg every 24 hours for the management of high blood pressure, ASA 81mg, taken PO every 24 hours and metoprolol 25 mg, taken every 12 hours for angina; fenofibrate 160mg daily for hypertriglyceridemia; and tamsulosin 0.4mg po bedtime for BPH.
• Allergies: Morphine

• Reproductive Hx: No reports of current and previous sexual activity.

ROS:

• GENERAL: · No reports of weight changes, fever, and chills.
• HEENT: No reports of any recent head injuries, ear and eye infections, or visual and hearing loss. There are also no reports of difficulty swallowing, mouth ulcers, or sore throat.
• SKIN: No reports of skin color inconsistencies, or scarring.
• CARDIOVASCULAR: No reports of palpitation, chest pain, or swelling in the extremities.
• RESPIRATORY: No reports of wheezing, excessive cough, or shortness of breath.
• GASTROINTESTINAL: No reports of bowel movement inconsistencies, abdominal distension, or abdominal pain.
• GENITOURINARY: No reports of dysuria, urinary frequency, urgency, or hematuria.
• NEUROLOGICAL: No reports of syncope, tremors, or dizziness.
• MUSCULOSKELETAL: No reports of muscle pain, stiffness, or mobility restrictions.
• HEMATOLOGIC: No reports of easy bruising, anemia, or excessive bleeding.
• LYMPHATICS: No reports of splenomegaly.
• ENDOCRINOLOGIC: No reports of cold intolerance, or excessive sweating

Objective:

Diagnostic results: MoCA 27/30,  ASRS-5 20/24;

Assessment:

Mental Status Examination: HG is alert and oriented to place and event. He is fully aware of his surroundings, including why he is in the clinic. He, however, seems restless. His memory and judgment are intact. His effect is euthymic.

Differential Diagnoses:

Attention Deficit Hyperactive Disorder (ADHD) F90. 9: ADHD is a psychiatric condition affecting people across the lifespan but is predominant in children. People with this disorder manifest with developmentally inappropriate levels of difficulty concentrating and hyperactivity. According to DSM-5-TR, a positive diagnosis of ADHD is made in the presence of inattentiveness, forgetfulness, disorganization, ease of losing things, and difficulty completing tasks. These symptoms must have been present for at least six months. They must also be causing disruptions in social functioning (Cabral et al., 2020). The patients in the case presented were forgetful, inattentive, easily lost things, had difficulty completing tasks, and disorganized. The symptoms had been present since his schooling days. This warranted the inclusion of this differential.

Depression F32.9: Depression is a common mood disorder. According to DSM-5-TR, a positive diagnosis of major depressive disorder is made in the presence of anhedonia and significantly depressed mood. It may also present with inattentiveness, lack of concentration, poor focus, and distractibility (Hussain et al., 2020).  In this case, the patient presented with a lack of concentration and poor focus on some tasks. This warranted the inclusion of this disorder in the differentials list. It was, however, ruled out due to the absence of key supporting features of depression, such as anhedonia and depressed mood.

Generalized Anxiety Disorder (GAD) F41.1: GAD is a common mental health illness. According to DSM-5-TR, a positive diagnosis of GAD is made in the presence of anxiety and other accompanying symptoms. People with this disorder will have constant worry and may likely suffer from distractibility, poor or loss of focus on some things, feelings of being overwhelmed, and irritability, among others (Mishra & Varma, 2023). This differential was included due to the presence of irritability and poor focus in the case presented. It was, however, ruled out due to a lack of other supportive features of the disorder.

Presumptive diagnosis: ADHD. Subjective findings ruled out GAD and depressive disorders. Diagnostic assessments from ASRS-5 20/24 also signified the presence of ADHD.

Reflections: The session was elaborate enough as it captured most aspects of subjective history required to make a presumptive diagnosis. The presumptive diagnosis is ADHD. Maintaining competent care is a legal consideration when managing the patient in this case. The caregivers should ensure that they treat the patient objectively without letting their emotions and biases cloud their judgment (Lamont et al., 2017). An ethical consideration in this case is beneficence. Caregivers, in this respect, should protect the welfare of their clients by giving them the best available care. As a point of health promotion to the patient, he will be educated on the risk factors for the disorder and the need for regular checkups to check for possible comorbidity.

References

Cabral, M. D., Liu, S., & Soares, N. (2020). Attention-deficit/hyperactivity disorder: Diagnostic criteria, Epidemiology, risk factors and evaluation in Youth. Translational Pediatrics, 9(S1). https://doi.org/10.21037/tp.2019.09.08

Hussain, M., Kumar, P., Khan, S., Gordon, D. K., & Khan, S. (2020). Similarities between depression and Neurodegenerative Diseases: Pathophysiology, challenges in diagnosis and treatment options. Cureus. https://doi.org/10.7759/cureus.11613

Lamont, S., Stewart, C., & Chiarella, M. (2017). Capacity and consent: Knowledge and practice of legal and healthcare standards. Nursing Ethics, 26(1), 71–83. https://doi.org/10.1177/0969733016687162

Mishra, A. K., & Varma, A. R. (2023). A comprehensive review of the Generalized Anxiety Disorder. Cureus. https://doi.org/10.7759/

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Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis.
Incorporate the following into your responses in the template:

Comprehensive Psychiatric Evaluation – Assessment, Diagnosis, and Clinical Reasoning

Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rule out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. 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.).