NRNP 6635: Psychopathology and Diagnostic Reasoning
Week 7 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation
CC (chief complaint): “I do not see any does not see any benefits with my medications.”
HPI:
RR is a 21-year-old Asian male who presents for a follow-up visit for ADHD and medication management. He reports that he does not see any benefits with his medications, and the current Adderall medication makes him more tense. He states that he does not want to go the stimulant way. RR reports having increased anxiety and depressive symptoms. The client reports that he is still experiencing insomnia and he is too tired to work or engage in physical exercises. Besides, he states that he does not currently have a therapist but will work on having one when he starts school. However, he mentioned that he watches a lot of sports and spends time with his family.
Past Psychiatric History:
- General Statement: The client first presented for psychiatric evaluation due to ADHD.
- Caregivers (if applicable): None
- Hospitalizations: None
- Medication trials: None
- Psychotherapy or Previous Psychiatric Diagnosis: Rejection Sensitive Dysphoria
Substance Current Use and History: He denies drug substance use, smoking, or taking alcohol.
Family Psychiatric/Substance Use History: No history of psychiatric or SUDs in the family.
Psychosocial History: RR lives with his parents and his younger sister. He is currently waiting to join university to study Theatre Arts. His hobbies include watching sports and acting, and he was a member of the Drama club in high school. He reports sleeping 3-4 hours daily with poor quality sleep due to insomnia.
Medical History:
- Current Medications: Adderall 5mg, guanfacine 1 mg, and Wellbutrin SR 100 mg daily.
- Allergies: None
- Reproductive Hx: No history of STIs.
ROS:
- GENERAL: Positive for increased fatigue. Denies fever, weight changes, or malaise.
- HEENT: Denies head injury, eye pain, excessive lacrimation, diplopia or blurred vision, ear pain/discharge, sneezing, nasal discharge, or pain when swallowing.
- SKIN: Negative for itching, rashes, or lesions.
- CARDIOVASCULAR: Denies dyspnea, edema, chest pain, or racing heart.
- RESPIRATORY: Denies cough, chest pain, wheezing, or difficulties in breathing.
- GASTROINTESTINAL: Denies abdominal distress, vomiting, or bowel changes.
- GENITOURINARY: Denies pelvic pain, dysuria, or blood in the urine.
- NEUROLOGICAL: Denies muscle weakness, paralysis, dizziness, or numbness.
- MUSCULOSKELETAL: Negative for limitations in movement.
- HEMATOLOGIC: Negative for bleeding or hx of anemia.
- LYMPHATICS: Denies lymph node swelling.
- ENDOCRINOLOGIC: No excessive perspiration, heat/cold intolerance, or polyuria.
Diagnostic results: No results available.
Assessment
Mental Status Examination:
Male client in his early 20’s. He is calm, alert, neat, and appropriately dressed. He maintains adequate eye contact and exhibits a positive attitude toward the clinician. The client has clear speech with normal rate and volume, and his thought process is goal-directed and logical. He denies auditory/visual hallucinations, homicidal ideations, or suicide ideations. No delusions, obsessions, or phobias were noted. His memory is intact, and he demonstrates good judgment.
Differential Diagnoses:
Attention Deficit Hyperactive Disorder (ADHD): ADHD manifests with impulsivity, hyperactivity, and inattention. Patients with the inattentive type are easily distracted, forgetful, disorganized, and do not follow instructions (Cabral et al., 2020). The patient had been previously diagnosed with ADHD and is on a follow-up visit. ADHD continues to be the primary diagnosis.
Generalized Anxiety Disorder (GAD): GAD presents with persistent and excessive anxiety or worries about everything. Other symptoms include restlessness, easy fatigue, concentration difficulties, muscle tension, irritability, and sleep disturbance (DeMartini et al., 2019). GAD is a likely diagnosis based on the client’s positive symptoms of fatigue, insomnia, and increased anxiety levels.
Major Depressive Disorder (MDD): MDD is a severe mood disorder that presents with persistent feelings of sadness and hopelessness and loss of interest in activities one previously enjoyed. Other clinical features include significant weight changes, sleep disturbances, fatigue, feelings of worthlessness, reduced capacity to think/concentrate or indecisiveness, and recurrent thoughts of death or suicidal ideations (Christensen et al., 2020). MDD is a differential based on the patient’s symptoms of fatigue, insomnia, and worsening depressive symptoms.
Reflections:
I agree with the preceptor’s diagnostic impression of ADHD since the patient did not exhibit other significant symptoms to warrant the diagnosis of MDD or GAD as the primary diagnosis. Patients with ADHD often have co-existing depression and anxiety symptoms similar to this patient. The preceptor stopped the patient’s Adderall, Guanfacine, and Wellbutrin treatment and discharged the patient for inability to manage medication. The PMHNP should implement treatment interventions associated with the best outcomes for ADHD patients. In this regard, I would have referred the patient for psychotherapy to help manage the ADHD, anxiety, and depression symptoms (Tourjman et al., 2022). Health promotion for this patient should focus on promoting healthier lifestyle practices with regard to diet and exercise. The patient should be recommended to exercise at least 30 minutes daily since it alleviates the severity of ADHD symptoms and improves cognitive functioning (Drechsler et al., 2020). Besides, he should be advised to eat foods that lower inflammation in the body as it helps the brain function better. This includes consuming more fruits, vegetables, and omega-3 fatty acid-rich foods like salmon or tuna and reducing the intake of white flour, processed foods, and sugar.
References
Cabral, M., Liu, S., & Soares, N. (2020). Attention-deficit/hyperactivity disorder: diagnostic criteria, epidemiology, risk factors and evaluation in youth. Translational pediatrics, 9(Suppl 1), S104–S113. https://doi.org/10.21037/tp.2019.09.08
Christensen, M. C., Wong, C., & Baune, B. T. (2020). Symptoms of Major Depressive Disorder and Their Impact on Psychosocial Functioning in the Different Phases of the Disease: Do the Perspectives of Patients and Healthcare Providers Differ?. Frontiers in psychiatry, 11, 280. https://doi.org/10.3389/fpsyt.2020.00280
DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized Anxiety Disorder. Annals of internal medicine, 170(7), ITC49–ITC64. https://doi.org/10.7326/AITC201904020
Drechsler, R., Brem, S., Brandeis, D., Grünblatt, E., Berger, G., & Walitza, S. (2020). ADHD: Current Concepts and Treatments in Children and Adolescents. Neuropediatrics, 51(5), 315–335. https://doi.org/10.1055/s-0040-1701658
Tourjman, V., Louis-Nascan, G., Ahmed, G., DuBow, A., Côté, H., Daly, N., Daoud, G., Espinet, S., Flood, J., Gagnier-Marandola, E., Gignac, M., Graziosi, G., Mansuri, Z., & Sadek, J. (2022). Psychosocial Interventions for Attention Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis by the CADDRA Guidelines Work GROUP. Brain sciences, 12(8), 1023. https://doi.org/10.3390/brainsci12081023