NRNP 6635 Assessing and Diagnosing Patients With Neurocognitive and Neurodevelopmental Disorders

NRNP 6635 Assessing and Diagnosing Patients With Neurocognitive and Neurodevelopmental Disorders

NRNP 6635 Assessing and Diagnosing Patients With Neurocognitive and Neurodevelopmental Disorders

Subjective:

CC (chief complaint): “psychiatric evaluation of attention deficit hyperactivity disorder.”

HPI: The 9-year-old female patient was accompanied to the psychiatric department by her mother following the positive findings of the completed attention deficit hyperactivity disorder (ADHD) questionnaire. The patient’s teacher also got an opportunity to complete the ADHD questionnaire based on her behavior and habits at school. According to the patient’s mother, her daughter has displayed difficulties in paying attention and is always forgetful. The patient’s teacher also reports similar symptoms at school, as the patient frequently forgets her assignments. At school, the patient fidgets a lot, displaying difficulties in sitting still on a chair. Additional symptoms reported include daydreaming, temperamental, and engaging in injurious activities. The patient started experiencing the above symptoms when she joined the kindergarten. Her mother claims that no treatment approach has been used so far in the management of the patient’s symptoms.

Past Psychiatric History:

  • General Statement: The patient presents with attention deficit and memory problems which affect her academic performance and other daily activities.
  • Caregivers (if applicable): The 9-year-old girl is under the care of one of her mothers.  
  • Hospitalizations: No history of hospitalization was reported.
  • Medication trials: No medication has been used to manage the patient’s current symptoms.
  • Psychotherapy or Previous Psychiatric Diagnosis: The patient has never been diagnosed with a mental disorder or taken part in therapy.

Substance Current Use and History: The patient lives and studies in a drug-free environment, with no exposure to cigarette or marijuana smoke.

Family Psychiatric/Substance Use History: No history of mental disorder or use of substances has been reported among any family member.

Psychosocial History: The patient is the only kid, who was being raised by her two moms. However, they recently got separated to resolve their marital issues, leaving the patient to stay with one, the current historian. The patient is in the 3rd grade, with poor performance due to her mental condition. She gets adequate sleep every night, for about 9 hours. Her PCP reports that the patient displays difficulties in consuming an entire meal as a result of being unable to sit down but she manages to get proper nutrition. She has a dog and also likes visiting art galleries and playing video games.

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Medical History: No history of any chronic medical condition was reported.

  • Current Medications: The patient is not on any medication.
  • Allergies: No known food, environmental, or drug allergies.
  • Reproductive Hx: Mother reports normal birth, with no birth defects. No family history of reproductive disorders.

ROS:

  • GENERAL: Generally healthy with no recent changes in body weight. Denies fever, chills, fatigue, headache, lethargy, or dizziness.
  • HEENT: Head: denies headache. Even distribution of hair. No signs of injury or trauma. Eyes: No redness, excessive tearing, itchiness, polyploidy, or pain. Ears: No tinnitus, hearing loss, inflammation, itchiness, or exudates. Nose & Throat: No congestion, sinus problems, bleeding nose, running nose, inflammation, or itchiness. No sore throat, swallowing difficulties, or bleeding gums.
  • SKIN: Warm but somehow dry. No lesions, bruises, lumps, redness, inflammation, or eczema.
  • CARDIOVASCULAR: No palpitations, murmurs, chest tightness, cyanosis, syncope, arrhythmias, or hypertension.
  • RESPIRATORY: No running nose, congestion, breathing difficulties, sneezing, wheezing, cough, sputum production, asthma, or chest discomfort.
  • GASTROINTESTINAL: No tenderness, hernia, abdominal distension, diarrhea, constipation, nausea, or vomiting.
  • GENITOURINARY: No urgency, frequency, or burning sensation when urination or incontinence. Has not yet experienced her first menses.
  • NEUROLOGICAL: No ataxia, headache, heat or cold intolerance, reduced appetite, paresthesia, or dizziness.
  • MUSCULOSKELETAL: No muscle or joint tenderness, stiffness, or inflammation. Confirm full range of movement in both lower and upper extremities.
  • HEMATOLOGIC: Denies easily bruising, bleeding gums, nose bleeding, anemia, or any other hematological disorder.
  • LYMPHATICS: No lymphadenopathy or splenectomy.
  • ENDOCRINOLOGIC: No hypothyroidism, hyperthyroidism, polyphagia, polyuria, or polydipsia.

Objective:

Physical exam: Vitals: Temp- 97.4 Pulse- 62 RR 14 95/60 Ht 4’5 Wt. 63lbs

Diagnostic results: To assess the patient for any underlying diseases complete blood count was ordered. Additional tests ordered for routine assessment include blood sugar tests, ELISA tests, basic metabolic panel, lipid profile, Hb test, and urine test for drugs. Imaging studies such as CT scans and X-rays of the head are also ordered to check for any anatomical deformities or signs of trauma, that may lead to the present symptoms. For further assessment of the patient’s signs of ADHD, the following screening tools were utilized, Conners Comprehensive Behavior Rating Scale (CBRS), National Institute for Children’s Health Quality (NICHQ) Vanderbilt Assessment Scale, and ADHD parent-teacher questionnaire (Halperin & Marks, 2019).

NRNP 6635 Assessing and Diagnosing Patients With Neurocognitive and Neurodevelopmental Disorders
NRNP 6635 Assessing and Diagnosing Patients With Neurocognitive and Neurodevelopmental Disorders

Assessment:

Mental Status Examination: The patient appears healthy and well-groomed in age-appropriate clothing. Her orientation is compromised as she keeps forgetting where she is, and why she is there. She however fidgets a lot. She is also impulsive and unable to sit still for quite a short period. She is very forgetful and seems distracted most of the time. Her mood is slightly elevated. She is very irritable. She speaks with a normal tone rate but is sometimes loud. Her thought process is intact. Denies hallucinations or delirium. Her thought content is appropriate for her age. Denies suicidal or homicidal or psychotic symptoms.

Differential Diagnoses:

  1. Attention Deficit Hyperactivity Disorder (ADHD): The diagnosis of ADHD as outlined in the DSM-V among children and adolescents requires a history of hyperactivity, behavioral problems, poor academic performance, distractibility, and inattention (Wolraich et al., 2019). The patient is also required to present with no less than 6 symptoms of hyperactivity or inattention or both leading to functional impairment just like for the patient in the provided case study. Consequently, the patient must start presenting with these symptoms before the age of 12 years, and the patient in the provided case study reported a set of symptoms immediately after joining kindergarten (Bélanger et al., 2018). From the mental status examination results, and provided patient history, in addition to the completed ADHD parent-teacher questionnaire, the patient qualifies for ADHD as the primary diagnosis.  
  2. Separation Anxiety Disorder (SAD): According to the DSM-V this disorder is assigned to patients who normally display anxiety or excessive fear when separated from an individual that they were strongly attached to like a family member (Becker et al., 2018). The patient was being raised by two mothers, who ended up separating leaving the patient to stay with one. Patients diagnosed with this disorder will also present with symptoms such as persistent worry about the unexpected event, nightmares about the separation, afraid of being left alone, and unusual distress (Sadaqa Basyouni, 2018). The patient in the provided case study is negative for most of these symptoms which disqualifies this diagnosis. 
  3. Unspecified Neurodevelopmental Disorder: According to the DSM-V, UNDD is usually diagnosed in patients who present with symptoms of a certain neurodevelopmental disorder but do not meet the criteria for any of them (Rivollier et al., 2019). It is one of the most common differential diagnoses for ADHD. The patient in the provided case study displayed ADHD symptoms, based on the complete ADHD questionnaire by both her mother and teacher. However, her mother was not sure whether the patient has this disorder, given that she was also separated from her other mother, which might contribute to her symptom and suggestion of another mental problem. This disorder will however be considered only if the patient fails to meet the diagnosis of ADHD.

Reflections: Based on the information provided, the PMHNP was very professional with the use of respectful language and maturing a healthy therapeutic relationship with the patient. The information gathered is quite adequate to support the diagnosis of ADHD. Since the patient’s mother was ready to seek medical attention based on the previously completed ADHD questionnaire, the PMHNP would have thus focused on discussing the available treatment options for the patient (Halperin & Marks, 2019). The patient’s mother has a legal obligation in making decisions concerning her child’s health. As such, the clinician must educate the patient’s mother on the advantages and disadvantages of each treatment option, and convince her of the most effective approach based on clinical judgment (Wolraich et al., 2019). Respecting the patient’s autonomy is crucial to promote positive treatment outcomes.

References

Becker, S. P., Schindler, D. N., Holdaway, A. S., Tamm, L., Epstein, J. N., & Luebbe, A. M. (2018). The Revised Child Anxiety and Depression Scales (RCADS): Psychometric Evaluation in Children Evaluated for ADHD. Journal of Psychopathology and Behavioral Assessment, 41(1), 93–106. https://doi.org/10.1007/s10862-018-9702-6

Bélanger, S. A., Andrews, D., Gray, C., & Korczak, D. (2018). ADHD in children and youth: Part 1—Etiology, diagnosis, and comorbidity. Paediatrics & Child Health, 23(7), 447–453. https://doi.org/10.1093/pch/pxy109

Halperin, J. M., & Marks, D. J. (2019). Practitioner Review: Assessment and treatment of preschool children with attention-deficit/hyperactivity disorder. Journal of Child Psychology and Psychiatry, 60(9), 930–943. https://doi.org/10.1111/jcpp.13014

Rivollier, F., Krebs, M.-O., & Kebir, O. (2019). Perinatal Exposure to Environmental Endocrine Disruptors in the Emergence of Neurodevelopmental Psychiatric Diseases: A Systematic Review. International Journal of Environmental Research and Public Health, 16(8), 1318. https://doi.org/10.3390/ijerph16081318

Sadaqa Basyouni, S. (2018). Separation Anxiety and its Relation to Parental Attachment Styles among Children. American Journal of Educational Research, 6(7), 967–976. https://doi.org/10.12691/education-6-7-12

Wolraich, M. L., Chan, E., Froehlich, T., Lynch, R. L., Bax, A., Redwine, S. T., Ihyembe, D., & Hagan, J. F. (2019). ADHD Diagnosis and Treatment Guidelines: A Historical Perspective. Pediatrics, 144(4), e20191682. https://doi.org/10.1542/peds.2019-1682