Select a patient that you examined during the last 3 weeks who presented with a disorder other than a mood disorder.
Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources.
Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
Objective: What observations did you make during the interview and review of systems?
Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis and why?
Reflection notes: What would you do differently in a similar patient evaluation?
Introduction on neurocognitive disorders
conclusion .Patient with Major Neurocognitive Disorder Essay Paper
A Comprehensive Psychiatric Evaluation of an Elderly Patient with Major Neurocognitive Disorder (Dementia)
The group of mental disorders referred to as Neurocognitive Disorders (NCD) principally affects senior citizens usually aged above 65 years. They are a distinct diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders or DSM-5. The most common characteristic among them all is the fact that there is marked disturbance in cognitive functioning in the patient. According to Sadock et al. (2015) and the American Psychological Association (APA, 2013), the areas or domains that are usually affected include the ability to solve problems, memory, interpersonal relationships, judgment, and language. The cognitive shortcomings seen in neurocognitive disorders are not developmental but acquired in old age. The symptoms normally begin with delirium or a reduced awareness of surroundings and confusion. The DSM-5 states that there are two main types of NCDs – major NCD (dementia) and mild NCD. These two have several etiological subtypes that include NCD due to Alzheimer’s Disease, NCD due to traumatic brain injury, frontotemporal NCD, and NCD due to HIV infection, amongst others (APA, 2013). This paper presents the comprehensive psychiatric evaluation of 71 year-old patient L.M. with major NCD or dementia.
CC (chief complaint): Patient L.M. was presented to the clinic with a complaint of progressive impairment of memory and spatial-temporal awareness for one month.
History of Presenting Illness (HPI): The patient is a 71 year-old Caucasian male who presents with progressive loss of memory and declining environmental awareness for a period of one month now. This is a deviation from his usual self as he is known by family. The historian who is a son denies any previous history of such symptoms. The onset of these symptoms was four weeks before the clinic visit. The location of these symptoms is the brain as the symptoms are neurocognitive in nature. The memory loss and impairment in spatial-temporal awareness is constant in duration and worsening. The characteristic of the symptoms can be described as insidious and debilitating. They are aggravated by activity around the patient and relieved by silence and calm. The symptoms can be noticed all the time and the son scores their severity at 8/10.
Past Psychiatric History:
- General Statement: The patient has been well in his old age since retirement and is only known to suffer from hypertension for which he is on medication. He has not had any mental health problems that have been serious as to warrant psychiatric evaluation. He has also never been put on any psychiatric medication for any reason whatsoever. As a child, he got all his immunizations as envisaged. As an adult, he has also got booster Tdp vaccinations as well as the pneumococcal and influenza vaccines. He has not had any disturbance in memory or other cognitive impairment that the family knows of until four weeks ago when the current symptoms began.
- Caregivers (if applicable): The patient is currently unable to carry out on his own (without being reminded) all the activities of daily living (ADLs) such as bathing, eating, and going to the toilet. This inability to take care of himself started when he started having memory lapses and impairment in environmental awareness.
- Hospitalizations: He has been hospitalized a total of 5 times in his lifetime as far as the son can remember. None of these was for a mental health issue.
- Medication trials: Patient L.M. has never participated in any medication trials as a subject or control.
- Psychotherapy or Previous Psychiatric Diagnosis: The patient has no history of previous psychiatric diagnosis or psychotherapy administered as a result of the same.
Substance Current Use and History: As an adult, the patient smoked cigarettes up to the age of 50 years when he was able to stop due to advice from his PCP. He has also always taken etoh in moderate quantities occasionally.
Family Psychiatric/Substance Use History: The patient’s father who is now deceased was an alcoholic who had to undergo therapy for the problem. He also suffered depression and was also treated for the same with successful remission until his death at the age of 68 years. His mother suffered from bipolar disorder and attempted suicide twice unsuccessfully. She died aged 57 from a massive hypertensive stroke. He has no siblings. His two adult children (both sons) are in good health and do not have any psychiatric health issues. His wife is currently in a nursing home with a diagnosis of Alzheimer’s Disease.
Psychosocial History: The client has been staying with his eldest son for the last three months and he was in the process of taking him to a nursing home when he started developing the current symptoms. The social support system for this patient is not very good as the other son lives out of state and only occasionally talks to him over the phone. At home, there are no obvious risks to his mental health as his eldest son does not drink or smoke. He however appears to have been affected to some extent by his father’s drinking and mental health issues while growing up.
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His current medications are:
- Metoprolol 50 mg orally BID for his hypertension (prescription)
- Benadryl 25 mg orally HS (OTC)
Allergies: NKDA. No known allergies to food or environmental allergens such as pollen, smoke, or dust.
Reproductive Hx: He is heterosexual, married and with two sons.
Review of Systems (ROS)
General: He reports no fever, recent loss of weight, fatigue, or malaise.
HEENT: There is denial of any form of migraine or headache. He denies double vision, squint, or photophobia. He also does not report tearing of the eyes. He was last at the ophthalmologist six months ago and does not wear glasses. He denies sneezing, a runny nose, loss of smell, epistaxis, or rhinitis. He denies having any ear discharge, hearing loss, or tinnitus. He denies using any hearing aids at the moment. He denies bleeding from the gums and any sort of ulceration in the mouth. He does not have difficulty in swallowing or a sore throat. He has not been to the ENT specialist for the last one and a half years.
Skin: He denies having any rashes, itching, or dermatitis.
Cardiovascular: He denies having any chest pains or palpitations. He has not also experienced coldness of extremities.
Respiratory: He denies coughing, dyspnea, coughing up blood, or wheezing while breathing. He does not get tired when he walks or climbs a short flight of stairs.
Gastrointestinal: He denies having nausea, diarrhea, or vomiting. His bowel habits have not changed and he has not experienced any sort of abdominal discomfort. His last bowel movement according to the son was the previous day at bedtime.
Genitourinary: He admits to occasional dribbling but denies frequency of micturition. He also denies dysuria or loss of bladder control. He denies ever having a prostatectomy done.
Neurological: He reports not remembering where he put things or even to take food or bathe. He however denies fainting, loss of consciousness, or dizziness. He has not suffered any seizures in the past.
Psychiatric: The patent reports a progressive impairment in memory and loss of awareness in terms of time and space (environmental surroundings). He cannot tell what time of the day it is or where he is at most times. He also cannot remember where he placed any item such as the phone three minutes ago. The son reports that these symptoms have adversely affected his functionality in daily activities and social functioning.
Musculoskeletal: He denies myalgia but reports frequent joint stiffness and arthralgia. He does not have a history of trauma or fractures.
Hematologic: The patient denies any history of clotting disorders or blood disorders.
Lymphatics: He denies lymphadenopathy or ver having a splenectomy.
Endocrinologic: He denies polydipsia and polyphagia. He also denies excessive diaphoresis or heat intolerance. He has never been a recipient of hormonal therapy too.
General: The patient is confused and not A&O x 3. He looks somewhat disheveled and is unshaven. Vital signs: BP 140/85 mmHg normal cuff and sitting; P 72 regular; T 98.5°F; RR 16 non-labored; Wt 69 kg; Ht 1.7 m; BMI 23.9 kg/m2.
HEENT: Both his pupils are equal, round, and reacting to light and accommodation (PERRLA). The extraocular muscles are intact (EOMI). No rhinorrhea or hypertrophy of his nasal turbinates. Intact nasal septum. Pinna and tragus non-tender. No otorrhea. Intact tympanic membranes bilaterally with adequate light reflex. Absence of gingivitis or ulceration of the oral cavity. No bleeding gums or teeth cavities. A good number of teeth missing. The throat is not erythematous and there is no exudate seen. Patient with Major Neurocognitive Disorder Essay Paper
Cardiovascular: Heart sounds S1 and S2 heard (regular rate and rhythm) with no murmurs, rub, or gallop discerned. He does not have any pedal edema.
Respiratory: The lung fields are clear with no wheezing, crepitations, rales, rhonchi, or crackles.
Neurological: GCS score of 13/15. There is no evidence of hemiparesis, hemiplegia, or facial palsy.
Psychiatric: The patient is confused, disoriented and bemused. He is puzzled and bewildered and cannot tell what time of the day it is or where he is. He also does not know why he is here.
- Laboratory: WBC 9.5 x 103/mcL
- Radiologic: CTA of the head (shows normal features).
Mental Status Examination (MSE)
The patient is a 71 year-old Caucasian male who is nether alert nor oriented in place, time, person, and event. His speech is clear but not goal-directed. He has no tics but gestures a lot. His self-reported mood is “happy”. Affect is euthymic and congruent to mood. There is no evidence of delusions or hallucinations. There is a lack of insight and judgment is impaired. The diagnosis made is Major Neurocognitive Disorder or Dementia, in agreement with the DSM-5 criteria for the condition (Sadock et al., 2015; APA, 2013; Stahl, 2013).
- Major Neurocognitive Disorder or Dementia
This is the most likely diagnosis according to the symptoms of this patient and his age. It is my primary diagnosis and the reason is that the client’s symptoms conform to the DSM-5 criteria for dementia. The symptom profile is congruent with the diagnostic profile of major NCD (dementia) in the DSM-5 (Hategan et al., 2017; Tsai & Boxer, 2014; APA, 2013). These DSM-5 criteria for dementia are as follows:
- There is evidence from the prevailing symptoms of impairment in cognitive performance compared to an earlier time. Several cognitive domains are affected, such as language, memory, perception, learning, and social cognition. This evidence is based on:
- The individual’s own concern for the appearance of the symptoms, concern of a family member or a person who knows the victim, or concern of a clinician who examines the client. Any of these persons observes that there has indeed been a notable decline in cognitive function; and
- A clinically documented significant impairment in cognitive function.
- The cognitive impairment makes the client unable to be independent in carrying out their daily functions including activities of daily living or ADLs (such as remembering to take medications, taking a shower, eating, or honouring an appointment).
- The deficits in cognition do not occur exclusively in the context of a delirium.
- The impairment in cognition is not attributable to another mental disorder such as schizophrenia or major depressive disorder (MDD).
- Persistent Delirium
According to the American Psychological Association (APA, 2013), this is the second most likely diagnosis after dementia. It is actually not easy to distinguish it from the primary diagnosis and the two may indeed be comorbid in the same patient. The distinction is however made by careful determination of arousal and attention span. An important distinguishing characteristic is that symptoms of delirium occur suddenly. For dementia, the symptoms are usually insidious and develop gradually over time. The cognitive decline can actually be tracked and be seen to be gradual. The rule of thumb separating the two is that delirium is characterised by inattention (APA, 2013).
- Normal Cognition
The third differential diagnosis in order of priority is normal cognition (APA, 2013). The American Psychological Association in the DSM-5 states that there is so much similarity between this differential diagnosis and dementia that the diagnostic boundaries are arbitrary at best. Distinguishing between the two is therefore challenging and requires experience. This is because the symptomatology of normal cognition and the primary diagnosis in this case is quite similar. The advice is to perform a very careful objective evaluation after thorough history taking if one is to grasp the distinguishing characteristics of the two (APA, 2013).
Given another chance, I would not do anything differently from what I have done in this case. This is because I have systematically evaluated the patient by beginning with collection of subjective information. I then proceeded to gather objective information which included physical examination and diagnostics to rule out other medical and mental conditions (Ball et al., 2019; Bickley, 2017). While at this, I performed a mental status examination or MSE to get to know the exact diagnosis of the patient. The assessment was then completed by coming up with three differential diagnoses based on likelihood. While doing all this, I kept the dignity of the client and treated them with respect (Entwistle, 2019; Motloba, 2018). I made sure I got their permission to examine before doing anything.
This was a case of NCD in the elderly which is a very common phenomenon. Following the laid down comprehensive psychiatric assessment procedure however enabled the correct diagnosis to be made. For good measure, two other possible differential diagnoses have been added in the order of likelihood. This patient suffers from dementia, now referred to as major NCD in the fifth edition of the DSM.
American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Author.
Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9th ed. Elsevier.
Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12th ed. Wolters Kluwer.
Entwistle, J.W.C. (2019). Noninformed consent and autonomy. The Annals of Thoracic Surgery, 108(6), 1610. https://doi.org/10.1016/j.athoracsur.2019.08.006
Hategan, A., Bourgeois, J.A., & Hirsch, C.H. (2017). Major or mild frontotemporal neurocognitive disorder. Geriatric Psychiatry, 403–428. https://doi.org/10.1007/978-3-319-67555-8_19
Motloba, P.D. (2018). Understanding of the principle of autonomy (Part 1). South African Dental Journal, 73(6), 418-420. http://dx.doi.org/10.17159/2519-0105/2018/v73no5a7
Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11th ed. Wolters Kluwer.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications, 4th ed. Cambridge University Press.
Tsai, R.M., & Boxer, A.L. (2014). Treatment of frontotemporal dementia. Current Treatment Options in Neurology, 16(11), 1-14. https://doi.org/10.1007/s11940-014-0319-0
Patient with Major Neurocognitive Disorder Essay Paper