Order Complex Case Study Presentation

Order Complex Case Study Presentation

At the end of this presentation, this class will be able to:

1. Distinguish neurocognitive disorders and their common symptoms.

1. Identify screening instruments for neurocognitive disorders.

1. Demonstrate understanding of the pharmacologic and nonpharmacologic treatments for neurocognitive disorders.

PRAC 6675 Comprehensive Psychiatric Evaluation

CC (chief complaint):

Patient BR states “I am doing good..I think?”..” I really don’t know what date , time or where I am today”.”My memory has been pretty bad”.

HPI:

BR is an 75-year-old Japanese male with signs and symptoms consistent with major neurocognitive disorder without behavioral disturbances. Patient was referred by assisted living facility staff for psychiatric evaluation due to the inability to manage finances because of neurocognitive impairment and family would like to file for probate conservatorship.Patient has a Folstein score of 5/30 and a clock drawing test score of 0. The patient has cognitive deficits that needed assistance with ADLs, medication management, prompting and set-up with meals. Patient currently lives in an assisted living facility due to his cognitive impairments and patient unable to independently provide it for himself.The patient’s cognitive deficits interfere with independently managing finances. Cognitively, He is alert to self only. His recent and remote memory is impaired. His concentration is poor His insight is poor.

Past Psychiatric History:

· General Statement: “I am doing good..I think?”..” I really don’t know what date , time or where I am today”.”My memory has been pretty bad”.

· Caregivers (if applicable): Niece applied for probate conservatorship and assisted living staff that provides around the clock assistance with ADLs.

· Hospitalizations: No hospitalizations. No history of self harm. No history of suicidal or homicidal behaviors.

· Medication trials: None prior to admission to assisted living facility

· Psychotherapy or Previous Psychiatric Diagnosis: None reported

· Substance Current Use and History: Denies.

Family Psychiatric/Substance Use History: None reported.

Psychosocial History: Patient lives with a roommate, Patient states that he was divorced for 21 years and thinks he has 1 son that he has no contact with. He states that he used to work in sales.

Medical History: CVA in 2020, HTN and HLD.

· Current Medications: Seroquel 25 mg by mouth as needed at bedtime for sleep. Eliquis 5 mg for CVA propylaxis , Lisinopril 10 mg for HTN , Atorvastatin 80 mg for HLD.

· Allergies: Strawberry

· Reproductive Hx: Denies any issues.

ROS:

· GENERAL: No weight loss, fever, chills, weakness, or fatigue.

· HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

· SKIN: No rash or itching.

· CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

· RESPIRATORY: No shortness of breath, cough, or sputum. No history of asthma and seasonal allergies.

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

· GENITOURINARY: No Burning on urination, urgency, hesitancy, odor, odd color

· NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

· MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

· HEMATOLOGIC: No anemia, bleeding, or bruising.

· LYMPHATICS: No enlarged nodes. No history of splenectomy.

· ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Physical exam: Performed by PCP.

Diagnostic tools:

Folstein test (MMSE) = 5/30

Clock Drawing Test = 0

Assessment:

Mental Status Examination:

Patient looks within the stated age. Patient is cooperative during the interview. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is minimal due cognitive impairment. There is no evidence of looseness of association or flight of ideas. His mood was “I think it is good” and with incongruent affect. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation.

Differential Diagnoses:

1. (F02.80) Major Neurocognitive disorder due to multiple etiologies, without behavioral disturbances – The patient presented with significant cognitive decline in memory and unable to take care of ADLs without assistance from staff. A substantial impairment in cognitive performance , preferably documented by standardized neuropsychological testing ( American Psychiatric Association , 2013). The diagnostic tools such as Folstein and Clock Drawing Test was used to aid in diagnosing the patient with this disorder.

2. (F01.50) Vascular Dementia without behavioral disturbances– The patient had medical history of CVA , HTN and HLD. This condition can be a r/o diagnosis due to the symptoms of neurocognitive deficits. Hypertension predisposes a person to the disease and approximately 10 to 15 percent of patients have coexisting vascular dementia and dementia of the Alzheimer’s type ( Sadock et al., 2015).

3. (F05) Delirium – Delirium is the name given to a set of symptoms that include severe confusion and disoriented thinking and often incorporate delusions and hallucinations ( Goldsmith , 2022). The patient was just medically cleared by PCP to a lower level of care such as an assisted living facility so it will not be this condition and there is no reported delusions or hallucinations.

Case Formulation and Treatment Plan:

BR is a 75-year-old Japanese male with signs and symptoms consistent with major neurocognitive disorder without behavioral disturbances. Patient has a Folstein score of 5/30 and a clock drawing test score of 0. Folstein’s Mini-Mental State Examination (MMSE) is recognized as a valid measure for detecting and grading dementia and cognitive impairment ( Vigliecca et al., 2012). The patient has cognitive deficits that needed assistance with ADLs, medication management, prompting and set-up with meals. The patient’s cognitive deficits interfere with independently managing finances. Cognitively, He is alert to self only. His recent and remote memory is impaired. His concentration is poor .His insight is poor. In regards to health promotion , patient lives in assisted living with 24/7 staff ,that provides assistance with basic needs , medication and ADLs. The patient will benefit from care in as assisted living facility that provides 24/7 care as the patient was unable to meet his own needs due to neurocognitive deficits. Pharmacologically , the patient presents without any behavioral disturbances and is currently living in a structured and locked facility with 24/7 staff and he will benefit from no changes in medication and just keep the Seroquel 25 mg that had been helpful with patient’s sleep. Signed all papers needed for probate conservatorship and given to assisted living staff per request of family member to manage patient’s finances. The patient will also benefit in engaging with psychotherapy with support group in the assisted living facility to have a structured environment and to have a common bond with other residents. Support groups typically allow group members to share their individual experiences , listen to others , provide information to one another , and to provide sympathetic understanding to one another ( Wheeler , 2020).

Reflection Notes:

I concur with the current treatment plan for this patient. The patient does not need any changes to medication as the patient is stable and appears without any behavioral issues. The patient lives in a structured facility with 24/7 that provides basic needs, medications and ADLs of the patient. Encourage staff to be supportive and knowledgeable in dealing with patient’s with neurocognitibe disorders.

Questions:

1. Do you agree with the differential diagnoses of the patient? Why or why not?

2. What other screening tools would you suggest for this case?

3. What other pharmacologic or non-pharmacologic intervention would you recommend for this patient?

References

American Psychiatric Association. (2013). Neurocognitive disorders.Diagnostic and statistical manual of mental disorders .5th ed.

Goldsmith, J. M. (2022). Delirium. Salem Press Encyclopedia of Health

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

Vigliecca, N. S., Peñalva, M. C., Molina, S. C., Voos, J. A., & Vigliecca, M. R. (2012). Is the Folstein’s Mini-Mental Test an Aphasia Test? Applied Neuropsychology: Adult, 19(3), 221–228. https://doi.org/10.1080/09084282.2011.643962

Wheeler , K. (Ed). (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidenced-based practice (3rd ed.). Springer Publishing.

Please read the attached soap discussion above and answer the three questions below. Please provide two references for each answer. Thank you.

Questions:

4. Do you agree with the differential diagnoses of the patient? Why or why not?

5. What other screening tools would you suggest for this case?

6. What other pharmacologic or non-pharmacologic intervention would you recommend for this patient?