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Essay, Nursing, Pages: 6

Assessing and Diagnosing Patients With Neurocognitive and Neurodevelopmental Disorders

Assessing and Diagnosing Patients With Neurocognitive and Neurodevelopmental Disorders

Subjective:

CC (chief complaint): “I simply can’t focus. Everyone else doesn’t appear to have this issue, but I am making dumb mistakes at work.”

HPI: Harold Brown, aged 60, complains of an inability to concentrate on his work as an architect in an engineering firm. He said the symptoms worsened with increased pressure on him at work due to tighter deadlines. He said he had made several mistakes, spotting ducts through solid walls and miscalculating the sizes of windows, which would have resulted in expensive errors on the project. These difficulties with concentration have gained momentum lately and have matched the increase in work pressure. On the other hand, Harold denies having these problems in the past when deadlines were not particularly pressing and his workload was lighter.

Social situations are not an exception for Harold, as he is easily distracted and fails to continue conversing. In addition, he claims to have issues with the way he pays his bills on time or with staying on top of daily tasks. Problems have persisted since childhood, during which he remembers he “would be easily distracted in school and couldn’t study or listen to a lecture.” No previous psychiatric treatment or diagnosis related to symptoms has been denied.

Past Psychiatric History:

  • General Statement: No history of treatment or diagnosis by a psychiatrist. He recalls that when he was a child, his mother once wanted to get him professional help due to his problems with concentration, but an evaluation was never made.
  • Caregivers (if applicable): Not relevant
  • Hospitalizations: No prior history of residential treatment or psychiatric hospitalizations exists.
  • Medication trials: Harold has never been prescribed psychiatric medications.
  • Psychotherapy or Previous Psychiatric Diagnosis: There is no past psychiatric diagnosis or history of psychotherapy.

Substance Current Use and History: On the weekends, Harold smokes cigars and has one glass of scotch. He admits to occasionally drinking coffee or soda to help him focus, but he denies using illegal drugs.

Family Psychiatric/Substance Use History: Family history of substance abuse or mental health problems not indicated.

Psychosocial History: Harold has no wife or kids and has never been single. He studied engineering, has a bachelor’s degree, and works full-time at an architectural firm. He does not communicate much with his family, and he seems closer to his younger brother. His hobbies include reading and spending time outdoors.

Medical History: Harold suffers from benign prostatic hyperplasia, hypertension, angina, and hypertriglyceridemia. He denies having ever experienced any neurological disorders or head trauma.

  • Current Medications: His current prescriptions include fenofibrate 160 mg for hypertriglyceridemia, valsartan 80 mg for angina, aspirin 81 mg for hypertension, Cozaar 100 mg for hypertension, and tamsulosin 0.4 mg for benign prostatic hyperplasia (BPH).
  • Allergies: Dilaudid
  • Reproductive Hx: Not mentioned.

ROS:

  • GENERAL: Absence of weight loss, fever, chills, or fatigue.
  • HEENT: There is an absence of hearing loss, blurred vision, or visual loss.
  • SKIN: No rashes, lesions, or itching.
  • CARDIOVASCULAR: No edema, palpitations, or chest pain are present.
  • RESPIRATORY: There is no cough, dyspnea, or wheezing.
  • GASTROINTESTINAL: Absence of nausea, vomiting, diarrhea, or constipation.
  • GENITOURINARY: He indicates benign prostatic hyperplasia (BPH) and no dysuria or hematuria.
  • NEUROLOGICAL: Difficulty with concentration. Absence of dizziness, headaches, or tremors.
  • MUSCULOSKELETAL: No joint pain, muscle weakness, or stiffness.
  • HEMATOLOGIC: There is no indication of anemia, bleeding, or bruising.
  • LYMPHATICS: No lymphadenopathy or a past history of splenectomy.
  • ENDOCRINOLOGIC: There is no polyuria, polydipsia, or heat/cold prejudice.

Objective:

Physical exam: Harold appears his stated age, 60, and is well-groomed. He is supportive and alert throughout the talk. The speech is coherent and usual in volume. He demonstrates logical and goal-directed thought processes. There are no abnormal motor activities, and his vital signs are within normal limits. His MOCA score of 28/30 shows mild cognitive worries, mainly with attention and delayed recall. His ASRS-5 score of 21/24 suggests significant attention deficits consistent with ADHD.

Diagnostic results: MOCA: 28/30, reflecting focus issues and deferred recall.

ASRS-5: 21/24, signifying attention deficits consistent with ADHD.

Assessment:

Mental Status Examination:

Harold is a 60-year-old male, and seems to be at this age. He is clean-shaven, professionally dressed according to the season and climate, and does not lose his temper while being interviewed. During interpersonal communication with Harold, he was friendly and compliant and showed good eye contact with the examiner. He is fully conscious and is aware of his surroundings, self, date, and event. He is fully aware of his body position and exhibited no extraneous movements. This includes twitching, shaking, and psychomotor agitation/retardation.

Harold is clean and well-groomed. He is appropriately dressed in casual business attire and demonstrates no evidence of neglect in his grooming or personal hygiene. He appears to be at his stated age and is physically healthy without visible physical impairment. Behavior assessment reveals Harold is cooperative, attentive, and apparently comfortable during the interview. He sat down without demonstrating restlessness, hyperactivity, or psychomotor agitation. There is no indication of abnormal gestures, movements, or mannerisms.

Harold’s speech is normal in rate, rhythm, and tone. His articulation is clear, and his vocabulary is consistent with his educational background as an engineer. He does not show any evidence of speech abnormalities; pressured speech, poverty of speech, or tangentiality is not observed in him. His speech is coherent, relevant, and logical. Further, Harold describes his mood as “neutral.” He denies any feelings of sadness, anxiety, or euphoria. His mood appears congruent with the topics discussed during the interview. In addition, the patient’s affect is appropriate to the content of the discussion and is congruent with his reported neutral mood. He smiles or frowns appropriately in response to the conversation and shows a full range of emotional expressions. His affect is not blunted nor exaggerated.

Regarding the thought process, all of Harold’s decisions are reasonable, purposeful, and sequential. No indication of loosening associations, flight of ideas, tangentiality, or circumstantiality is observed. The answers correspond to the questions asked, and he does not seem to have problems understanding the rest of the conversation.

Making his own assessment, Harold categorically denies having delusions, hallucinations, and paranoid ideas of any kind. No features of ideational narcissism, persistent thought disorder, or thought alienation are seen. He also negates all questions relating to obsession and compulsion. Thus, Harold does not identify any irrational fear or phobia that the researchers found necessary to diagnose him with.

Harold reports no auditory or visual hallucinations. In the case of diagnosing psychotic disorders, there is almost no indication of any kind of illusions and panorama disturbances. The disturbances found in depersonalization and derealization are lacking in this client during the evaluation.

Harold is fully oriented with regard to time, place, person, and situation. His short-term and, presumably, long-term memory function will remain unimpaired. He gave information about his personal background, work experience, and health history. Harold obtained 28/30 on MOCA, indicating mild impaired cognition, more specifically impaired attention and delayed recall. His executive skills, such as problem-solving and following instructions like when performing his engineering duties, are preserved.

Harold has a reasonable awareness of his present problems, majoring in the current concentration problems in his line of work. He also accepts the proposition that his difficulties attending have resulted in poor productivity for his job and commonly unmanageable interpersonal crises. He knows these illnesses have manifested in childhood but never visited a doctor before.

Harold seems to have sound judgment. He can make informed decisions and weigh the consequences of his actions. He acknowledges that his difficulty concentrating has led to mistakes at work, but he understands the need to address these problems and seeks help to improve his performance and overall well-being. Lastly, Harold refutes any recent or past suicidal or homicidal ideation. He reports no history of self-harm or harm to others.

Differential Diagnoses:

  1. Attention-Deficit/Hyperactivity Disorder (ADHD), predominantly inattentive presentation (Primary Diagnosis):

The DSM-5-TR criteria state that persistent patterns of inattention that impair functioning are a hallmark of ADHD (Koutsoklenis & Honkasilta, 2023). Harold makes casual mistakes, struggles to maintain focus, organizes his duties poorly, and avoids jobs that require prolonged mental effort—all signs of inattention. His symptoms began in childhood, as evidenced by his difficulty concentrating in school and being easily distracted. The severity of his symptoms has increased under work-related pressure, affecting his job performance. Pertinent positives include his high ASRS-5 score (21/24), which is consistent with ADHD. Pertinent negatives include the absence of hyperactivity or impulsivity, ruling out the hyperactive-impulsive or combined presentation of ADHD.

  1. Mild Neurocognitive Disorder (NCD):

Harold’s MOCA overall raw score of 28/30 shows mild impairment in attention and delayed recall test. As categorized in the DSM-5-TR, mild neurocognitive disorder is characterized by a mild impairment or decline from a prior higher level of functioning in one or more domains (Quach et al., 2023). However, Harold does not exhibit significant memory loss, disorientation, or perceptual-motor deficits that are hallmarks of NCD. His primary difficulties seem to be focused on attention and executive functioning rather than a global cognitive decline. While the lack of memory loss or decline in other cognitive domains is relevant negatives, mild impairment in the MOCA is a noteworthy positive.

  1. Generalized Anxiety Disorder (GAD):
    Generalized anxiety disorder is identified with increased worry and concern about most activities. Harold claims to be under stress at work, yet his anxiety is transitory and limited to his workplace. According to the DSM-5-TR, GAD requires symptoms of excessive worry for at least six months about a range of events, which is not evident in Harold’s case (Munir & Takov, 2022). Rather than widespread anxiety or concern, his symptoms are mostly associated with inattention and task management. Work-related stress is a pertinent positive, but the lack of excessive, widespread concern or physical symptoms like weariness and restlessness—both necessary for a GAD diagnosis—is a pertinent negative.

Critical-Thinking Process to Formulate Primary Diagnosis

Attention should be paid to the fact that the primary diagnosis of ADHD will be lifelong symptoms of inattention by Harold, which meet the DSM-5-TR criteria. His problems with paying attention and being organized, his failure to keep focus, and the high results of ASRS-5 indicate a diagnosis of ADHD (Brevik et al., 2020). His symptoms have been since childhood and are aggravating under work pressure. Whereas mild neurocognitive disorder could be a consideration because of the client’s age and mild impairment on the MOCA, Harold’s biggest concern seems to be more with attention and executive functioning rather than global cognitive decline. GAD was ruled out since pervasive worry or anxiety was not persistent. Assembling these pieces allowed the best-fitting diagnosis of ADHD for the patient.

Reflections:

The main improvement I would make if I were to do this session again is to pay more attention to the aspects of Harold’s childhood when attention difficulties affected other facets of his life, including personal relationships. Increasing the information about his family history of psychiatric disorders or “cognitive” problems could also contribute to it.

Ethical and legal factors involve making sure Harold is aware of his symptoms or developments that could lead to the diagnosis of cancer and the possible treatment that can be done. Particularly, his cultural background should be taken into account, as well as how the work context affects his stress and attention issues. Health promotion should aim at preventing work-related stress and dealing with symptoms that worsen with age (Tamminga et al., 2023). Work and income, education, and healthcare access also should be taken into consideration when prescribing therapies.

References

Brevik, E. J., Lundervold, A. J., Haavik, J., & Posserud, M.-B. (2020). Validity and accuracy of the adult attention-deficit/hyperactivity disorder (ADHD) Self-Report Scale (ASRS) and the Wender Utah Rating Scale (WURS) symptom checklists in discriminating between adults with and without ADHD. Brain and Behavior, 10(6), e01605. https://doi.org/10.1002/brb3.1605

Koutsoklenis, A., & Honkasilta, J. (2023). ADHD in the DSM-5-TR: What has changed and what has not. Frontiers in Psychiatry, 13(1064141). https://doi.org/10.3389/fpsyt.2022.1064141

Munir, S., & Takov, V. (2022). Generalized anxiety disorder. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441870/

Quach, L. T., Pedersen, M. M., Ogawa, E., Ward, R. E., Gagnon, D. R., Spiro, A., Burr, J. A., Driver, J. A., Gaziano, M., Dhand, A., & Bean, J. F. (2023). Mild neurocognitive disorder, social engagement, and falls among older primary care patients. Archives of Physical Medicine and Rehabilitation, 104(4), 541–546. https://doi.org/10.1016/j.apmr.2022.10.008

Tamminga, S. J., Emal, L. M., Boschman, J. S., Levasseur, A., Thota, A., Ruotsalainen, J. H., Schelvis, R. M., Nieuwenhuijsen, K., & van der Molen, H. F. (2023). Individual-level interventions for reducing occupational stress in healthcare workers. Cochrane Database of Systematic Reviews, 2023(5). https://doi.org/10.1002/14651858.cd002892.pub6

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Question 

Neurodevelopmental disorders begin in the developmental period of childhood and may continue through adulthood. They may range from the very specific to a general or global impairment, and often co-occur (APA, 2022). They include specific learning and language disorders, attention deficit hyperactivity disorder (ADHD), autism spectrum disorders, and intellectual disabilities. Neurocognitive disorders, on the other hand, represent a decline in one or more areas of prior mental function that is significant enough to impact independent functioning. They may occur at any time in life and be caused by factors such brain injury; diseases such as Alzheimer’s, Parkinson’s, or Huntington’s; infection; or stroke, among others.

For this Assignment, you will assess a patient in a case study who presents with a neurocognitive or neurodevelopmental disorder.

TO PREPARE:

  • Review this week’s Learning Resources and consider the insights they provide. Consider how neurocognitive impairments may have similar presentations to other psychological disorders.
  • Review the Comprehensive Psychiatric Evaluation template, which you will use to complete this Assignment.
  • By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
  • Consider what history would be necessary to collect from this patient.
  • Consider what interview questions you would need to ask this patient.
  • Identify at least three possible differential diagnoses for the patient.

    Assessing and Diagnosing Patients With Neurocognitive and Neurodevelopmental Disorders

    Assessing and Diagnosing Patients With Neurocognitive and Neurodevelopmental Disorders

BY DAY 7 OF WEEK 10
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.
Incorporate the following into your responses in the template:

  • 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 rules 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.).

Resources: