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.

 
Neurocognitive and Neurodevelopmental Disorders
Patient Initials: H.B.

Age: 60 years

Gender: Male
Subjective:
CC (chief complaint): The patient (H.B.) reports that he has difficulty with concentration. According to him, his condition worsened due to heightened pressure at the workplace involving accelerated deadlines.

HPI: The patient is a 60-year-old male. He reports that he has difficulty with concentration. He works at an architectural engineering firm, and he reports that job pressure emanating from accelerated deadlines has worsened his condition. According to him, this has made him commit silly mistakes. Further evaluation reveals that the patient had similar problems in school. He reports that he had difficulty concentrating when preparing for examinations. According to him, he was easily distracted by external and internal environments. He admits that he rarely listens to the lectures delivered by the chief of the department because he is usually preoccupied with other trivial issues. He reports that he has difficulty organizing himself. For instance, he forgets his shoes, socks, phone, and even jacket. According to H.B., he forgets to pay his bills on time and is always penalized for late payments. He reports being hyperactive but notes that the condition has improved significantly compared to his school days. H.B. takes one scotch drink and a cigar weekly. He has other comorbidities such as hypertension, angina, hypertriglyceridemia, and benign prostate hyperplasia. He is not married and has no children.

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Past Psychiatric History:
General Statement: This is the first time that the patient has presented himself for evaluation. This process was initiated by his supervisor. The patient reports that his mother never took him for evaluation during his childhood.

Caregivers (if applicable): The patient does not have a caregiver.

Hospitalizations: The patient denies any hospitalization

Medication trials: The patient reports that he has never been treated with medications for ADHD.

Psychotherapy or Previous Psychiatric Diagnosis: The patient reports that he has never received any psychotherapy. Furthermore, he has never been diagnosed with a psychiatric condition.

Substance Current Use and History: H.B. takes one scotch drink and a cigar weekly (on weekends). Furthermore, the patient takes coffee once in a while. He reports that it helps him to focus.

Family Psychiatric/Substance Use History: The patient did not provide pertinent family psychiatric or substance use history.

Psychosocial History: The patient is not married and has no children. He reports that he dates casually. He has one younger brother. The patient has a bachelor’s degree in engineering and works at an architectural engineering firm. The patient denies any legal issues. Also, he denies any history of trauma and violence.

Medical History: Evaluation reveals that the patient has other comorbidities: hypertension, angina, hypertriglyceridemia, and benign prostate hyperplasia.

Current Medications: Cozaar 100mg daily for hypertension, ASA 81mg PO daily and valsartan 80mg daily for angina, fenofibrate 160mg daily for hypertriglyceridemia, tamsulosin 0.4mg PO bedtime for benign prostate hyperplasia.

Allergies: The patient is allergic to Dilaudid.

Reproductive Hx: No reproductive history of concern was reported.
ROS:
GENERAL: No weight loss, weakness, fever, or chills

HEENT: Eyes: No visual loss, conjunctivitis, blurred vision, diplopia, or retinal edema. No hearing loss, nasal congestion, pharyngitis, sneezing, or rhinorrhea.

SKIN: No bruising, ulcers, rashes, or pruritus. Normal turgor.

CARDIOVASCULAR: Has elevated blood pressure and chest pain

RESPIRATORY: No dyspnea, cough, respiratory distress, or sputum.

GASTROINTESTINAL: No nausea, constipation, anorexia, vomiting, abdominal pain, or diarrhea.

GENITOURINARY: The prostate gland is enlarged. No discharge, hesitancy, dysuria, nocturnal enuresis, or urgency.

NEUROLOGICAL: No headache, paralysis, syncope, numbness, dizziness, or ataxia. Normal proprioception.

MUSCULOSKELETAL: No arthritis, muscle pain, stiffness, or myalgia

HEMATOLOGIC: No bleeding, anemia, leukocytosis, bruising, or leukopenia.

LYMPHATICS: No enlarged nodes.

ENDOCRINOLOGIC: No hyperhidrosis., insulin resistance, polydipsia, polyuria, or cold intolerance
Objective:
Physical exam: The client is disorganized and untidy. His hair is unkempt. He has worn his sweater incorrectly. On the left leg, he is wearing one sock. The patient experiences intensely unsettling ideas and jumbled thinking.

Diagnostic results: The ADHD Self-Report Screening Scale for DSM-5 (ASRS-5) and the Montreal Cognitive Assessment (MoCA) screening assessments are relevant to this patient. The patient’s ASRS-5 score is 21/24. This suggests that H.B. is likely to have ADHD (a neurodevelopmental disorder) (Anbarasan et al., 2020). The patient’s MoCA score is 28/30. This suggests that H.B. is unlikely to have any form of cognitive impairment (neurocognitive disorder) (Potocnik et al., 2020). In this context, further laboratory tests are not necessary.
Assessment:
Mental Status Examination:
H.B.’s physical characteristics correspond with his reported age. He is oriented to time and place. Also, he participates actively in the interview with appropriate use of tonal variation. Furthermore, he demonstrates appropriate use of nonverbal cues, as evidenced by eye contact. His thoughts are organized, and he questions adequately. The patient does not report any suicidal ideation or thoughts of self-harm.
Differential Diagnoses:
The patient’s potential diagnoses include attention deficit hyperactivity disorder (ADHD), Alzheimer’s disease, and delirium.
Attention Deficit Hyperactivity Disorder (ADHD)
ADHD can be categorized into inattentive, hyperactive, or combined (both inattentive and hyperactive). According to the DSM-5 inattentive ADHD is diagnosed when a person presents with at least six of the symptoms in the diagnostic criteria for at least six months (Harrar, 2022). They include careless mistakes, difficulty concentrating when executing tasks, inability to listen to what is being said, failure to adhere to instructions and to complete assigned tasks, inability to organize tasks or activities, easily distracted, forgetfulness, and easily misplacing items used in routine work (CDC.gov, 2022). Furthermore, hyperactive or impulsive ADHD is diagnosed when a patient presents with at least six of the symptoms in the diagnostic criteria for at least six months (CDC.gov, 2022). They include fidgeting, tapping and squirming, inability to remain seated as required, running and climbing in unnecessary settings, inability to play quietly, talking excessively, tendency to interrupt or intrude on other people, and blurting out responses to incomplete questions (CDC.gov, 2022). Typically, the symptoms manifest by the age of twelve years. In this scenario, H.B. admits that he is disorganized and forgets his shoes and other personal items. Also, he admits to committing silly mistakes. He reports that he is usually uncomfortable in the chair. This is suggestive of squirming when seated. Furthermore, he reports that his condition began in his childhood, and he had difficulties concentrating in school. As such, the patient has combined ADHD. The diagnosis of ADHD is confirmed by the ASRS-5 score of 21/24.
Alzheimer’s Disease (AD)
According to the DSM-5, AD can be diagnosed based on the severity of the disorder. The major neurocognitive decline caused by AD presents a family history of the disease, a significant decline in learning and memory, significant disturbance in cognition, and the absence of other neurodegenerative disorders (PsychDb, 2022). Minor neurocognitive decline presents with similar manifestations (PsychDb, 2022). Typically, AD presents with a decline in memory, confusion, difficulty settling bills, inattentiveness, inability to recognize family members, and amnesia (Mok et al., 2020). Various aspects rule out this diagnosis. Firstly, the patient demonstrates intact memory and can recall various aspects of his childhood. Secondly, the patient scored 28/30 on the MoCA test. Thirdly, the patient’s judgment is not compromised.
Delirium
According to the DSM-5, firstly, delirium is characterized by impaired attention and awareness (Alagiakrishnan, 2019). This implies that patients are not oriented to place. Secondly, DSM-5 reports that delirium develops rapidly within hours to days (Alagiakrishnan, 2019). As such, it is an acute change in a person’s attention and orientation; its severity fluctuates within the day. Thirdly, DSM-5 reports that delirium presents with disturbed cognition (Alagiakrishnan, 2019). Disturbed cognition may manifest via memory loss and disorganized speech. Fourthly, impaired attention, awareness, and cognition can not be attributed to an underlying neurocognitive disorder (Alagiakrishnan, 2019). Fifthly, patient history, physical examination, and diagnostic results indicate that other underlying medical conditions, substance use, or withdrawal cause the disturbance. Various observations rule out this diagnosis. H.B. is oriented to place. Furthermore, the patient’s condition started during childhood and did not develop rapidly over days. In addition, the patient doesn’t have any underlying condition that can be physiologically linked to his condition.
Reflections:
I agree with my preceptor’s assessment and diagnostic impression of the patient. The ASRS-5 score of 21/24 suggests that the patient has ADHD. I agree with this diagnostic impression because the patient fulfilled DSM-5 diagnostic criteria for inattentive and hyperactive ADHD. If I were to redo the session, I would take a comprehensive patient history. Notably, I would focus on the patient’s family history. This information is essential to promoting adherence to the treatment plan and ruling out some differential diagnoses, such as Alzheimer’s disease. Furthermore, I would have referred the patient to other members of the interdisciplinary team to evaluate and manage his comorbidities.

I would have embraced ethical principles such as beneficence when developing the patient’s treatment plan. Also, I would have embraced justice and avoided discriminating against the patient. I would have evaluated social determinants of health such as the community and society to determine how they impact the patient’s well-being. Furthermore, I would have educated the patient on coping mechanisms and the local community resources.
References
Alagiakrishnan, K. (2019). Delirium Clinical Presentation. https://emedicine.medscape.com/article/288890-clinical#:~:text=DSM%2D5%20diagnostic%20criteria%20for,%2C%20sustain%2C%20or%20shift%20attention.