NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation

This paper examines the case of Sarah Higgins, a nine-year-old female patient with neurocognitive and neurodevelopmental disorders. According to her PCP, Sarah has never been diagnosed nor treated for psychological disorders and attained all her developmental milestones on time. Besides, all her vaccinations are current, and she sleeps well and gets proper nutrition. Nevertheless, she experiences eating difficulties and other problems because she cannot settle down or concentrate on a particular task for an extended period.

CC (chief complaint): Sarah complained that she hardly remembered anything, including her teacher’s instructions in school and even some of the questions I posed as we interacted. Secondly, Sarah stated that she felt unsettled, fidgeted a lot, and thus unable to settle down or complete a specific activity. Again, she loses her belongings, daydreams in school, and loses her temper sometimes, especially when people think she is pretending.

HPI: The patient’s mother reported that she was exceedingly active to the extent that she risked getting hurt when she was younger. Fortunately, such behaviour waned almost entirely as she grew up.  

Past Psychiatric History:

• General Statement: The patient often forgot most things and had trouble settling and concentrating in school.
• Caregivers (if applicable): The patient was accompanied by her parent but had other caregivers.
• Hospitalizations: The patient has never been hospitalized.
• Medication trials: None.
• Psychotherapy or Previous Psychiatric Diagnosis: The patient has never undergone psychotherapy or psychiatric diagnosis.

Substance Current Use and History: The client has no previous or current drug or substance use history.

Family Psychiatric/Substance Use History: The client’s family does not have a psychiatric or substance use history.

Psychosocial History: The patient is a female aged nine years old and never mentioned any traumatizing incidents in her childhood. However young, she does not live with her parents and seems disturbed, distant and indifferent due to their separation.

Medical History:

• Current Medications: None.
• Allergies: None.
• Reproductive Hx: The client does not have a notable reproductive history.

ROS:

• GENERAL: Although the patient was polite, she was relatively unresponsive and did not answer most questions. Again, she gave scanty information that could not establish the underlying cause of the problem.
• HEENT: The patient did not exhibit any visual or auditory issues. Her medical history indicated that she has an ordinary sense of smell.
• SKIN: The patient’s skin was visibly healthy, with no burns, rashes, bruises, itching, or redness.
• CARDIOVASCULAR: The patient recorded low blood pressure.
• RESPIRATORY: The patient never reported any respiratory illnesses or complications.
• GASTROINTESTINAL: The patient exhibited normal bowel movement and did not exhibit vomiting, nausea, cramps, and diarrhoea.
• GENITOURINARY: The client never reported any issues such as pain during urination, chronic renal failure, or faecal incontinence
• NEUROLOGICAL: The patient never reported dizziness, headaches, arm or back pains. However, she forgets a lot and loses her belongings.
• MUSCULOSKELETAL: The patient exhibited normal movement and attained her developmental milestones appropriately.
• HEMATOLOGIC: No blood or related disorders were present.
• LYMPHATICS: The client’s lymph nodes were normal, with no signs of inflammation, swelling, or redness.
• ENDOCRINOLOGIC: The patient never exhibited any endocrine or related problems.

Objective:

Physical exam: A physical examination WNL was recommended. Besides the conventional tests, the patient’s neurological history was examined. According to De Lahunta (2020), neurological history is among the most crucial components of a neurological diagnosis. The neurological history examination involves interactions, observations, and discussions that provide valuable information for a medical examination. In addition, the patient underwent a functional magnetic resonance testing (MRI) procedure.

Diagnostic results: The client’s responses, behaviour, and reactions during the physical examination indicated the presence of neurocognitive or neurodevelopmental disorders.

Assessment:

Mental Status Examination: The client was polite and responded appropriately to the questions. Although she participated willingly, the client could not answer most of the questions since she never remembered much. Again, she seemed indifferent to the procedure, and her mother responded. Although her speech was clear and coherent, her thoughts and concentration were exceedingly disrupted.

Differential Diagnoses:

Attention Deficit Hyperactivity Disorder

According to Belanger et al. (2018), Attention-deficit/hyperactivity disorders denotes a severe psychological disorder in which patients experience various problems, including difficulties concentrating on a particular task, impulsive behavior, and hyperactivity. ADHD is among the most prevalent disorders affecting children and progressing into adulthood (Sahal et al., 2018). Although extensive studies indicate that the symptoms related to ADHD reduce gradually, most patients do not overcome the condition. According to DSM-5, ADHD presents in three main types. Firstly, ADHD patients can be predominantly inattentive. In this case, most of the symptoms are related to inattention. Secondly, ADHD patients can be hyperactive and therefore impulsive. Thirdly, ADHD patients may exhibit both inattention and hyperactivity. Although there is no known cause of ADHD, recent studies posit that genetic, environmental factors and injuries affecting the central nervous system are the most notable causes. The most notable risk factors for ADHD include exposure to harmful toxins, family history of the illness, and premature birth. As per the DSM-5, ADHD adversely affects academic performance, lowers self-esteem, triggers injuries, and impairs the ability to create and maintain healthy relationships (2013). The patient exhibited symptoms identified in the DSM-5 criteria, and hence, ADHD was selected as one of the diagnoses.

Autism Spectrum Disorder

Autism Spectrum Disorder refers to a mental illness linked to brain development that interferes with how a person interacts, relates, and communicates with others. According to Lord (2018), ASD symptoms present in early infancy and increase with age. Autistic children exhibit a broad range of symptoms that interfere with communication and behaviour. For instance, they may fail to respond to their name, have poor eye contact, and delayed speech. Again, they may have repetitive behaviour, self-harm, retreat to their thoughts, and focus on a particular activity (2013). Like most psychological illnesses, ASD is linked to genetic and environmental causes. The most notable risk factors related to Autism include a child’s sex, parental age, premature birth, and other illnesses. ASD interferes with learning, causes stress, triggers victimization, and reduces the ability to live or work independently (Lord, 2018). The patient’s symptoms are some of the criteria used in diagnosing ASD as per the DSM-5.

Specific Learning Disabilities

According to Tannock (2014), Specific Learning Disabilities refer to a neurodevelopmental disorder that affects the brain and interferes with essential learning skills like writing, reading, and doing arithmetic. Since these disorders adversely affect learning, they often present and are identified. Nevertheless, they may also be detected later in advanced education or employment. According to the DSM-5, SLD symptoms manifest differently according to the culture and age of learners. However, SLD primarily presents as learning difficulties during instruction and assessment (2013). Although SLD is often recognized as a learning disability, it differs from physical handicaps that impede learning, such as visual and auditory defects. In this paper’s scenario, the learner exhibited various difficulties in learning, like difficulties in understanding instructions and failing in her assignments. In this sense, SLD would be a proper differential diagnosis.

Reflections:

Neurocognitive and neurodevelopmental disorders are complex because they do not have specific causes, prevention, or cure. Most neurodevelopmental and neurocognitive disorders have similar symptoms and thus are difficult to identify without proper diagnosis. From this perspective, mental health providers should employ holistic and profound diagnostic tools which determine the interventions. The client, in this case, was a child and never understood the severity of her condition. Although her parent assisted best, the patient did not reveal any factors linked to the problem. If it were possible to conduct the session again, I would examine the child privately to understand the background of the problem. Nonetheless, such action would compromise the client’s autonomy regardless of the benefit to the treatment process.

Reference

American Psychiatric Association, & American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA.

Belanger, 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.

De Lahunta, A. (2020). The neurologic examination. Clinical Small Animal Internal Medicine, 727-739.

Lord, C., Elsabbagh, M., Baird, G., & Veenstra-Vanderweele, J. (2018). Autism spectrum disorder. The Lancet, 392(10146), 508-520.

Sayal, K., Prasad, V., Daley, D., Ford, T., & Coghill, D. (2018). ADHD in children and young people: prevalence, care pathways, and service provision. The Lancet Psychiatry, 5(2), 175-186.

Tannock, R. (2014). DSM-5 changes in diagnostic criteria for specific learning disabilities (SLD): The implications. International Dyslexia Association.