Diagnosis Among Patients

Discussion Responses
Write a BRIEF response to the below 2 writers, including answering the 3 Questions provided at the end of their presentation.
Providing additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient.

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Post #1
Writer: J.Q
Objectives:

1. By the end of this presentation, you will be able to identify the symptoms linked to OCD and apply differential diagnosis.
2. At the end of this presentation, you will be able to successfully identify and properly engage in conversation between patients (especially minors) and parents to ease transition into being diagnosed with the disorder as well as providing resources.
3. At the end of this presentation, you will be able to apply different treatment plans and therapies to patients who may present with OCD, OCPD, or ADHD and other medical cases.
   Case Introduction:
   The patient, a 12-year-old African American boy, presents with his mother for an initial visit due to a complaint of excessive hand washing and trouble sitting and focusing. The patient has been diagnosed with the inattentive ADHD, obsessive-compulsive personality disorder (OCPD), and obsessive-compulsive disorder (OCD). The mother of the patient notes that he exhibits signs of inattentiveness, challenges in adhering to instructions, and consistently submits his schoolwork beyond the deadline due to forgetfulness, leading to unsatisfactory academic performance. In addition, the patient’s mother noted that he had difficulty sleeping and engages in repetitive behaviors, such as compulsively washing his hands after showering and doing so every 20 minutes. The treatment approach for the patient involves initiating therapy sessions, psychoeducation, starting Adderall XR 10 mg orally daily, and hydroxyzine 5 mg orally at bedtime as needed and a follow up after 2 weeks.
   Subjective:
   CC (chief complaint): “My mother says I can’t focus and sit still.”
   HPI: C.Q is a 12-year-old African American male and the youngest of his two siblings. The patient’s mother is seeking treatment for his son who has been referred by a psychologist for management for a diagnosis of attention deficit hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD) and obsessive compulsive personality disorder (OCPD). The patient has been in stable condition until he began exhibiting unusual rituals at home, such as constantly washing his hands after bathing, and claiming the presence of germs everywhere in the house. Additionally, he experiences difficulties in maintaining concentration during school. According to his mother, he frequently becomes physically disengaged and fails to finish tasks when requested to do so. Furthermore, he exhibits symptoms of inattentiveness, struggles with adhering to instructions, lacks self-confidence, and consistently submits tasks past their due dates due to forgetfulness, leading to unsatisfactory outcomes. In addition, his mother noted that he had difficulties with sleep.
   Substance Current Use: None
   Medical History: The patient has no medical history of any illness and no record of any surgical procedures.

• Current Medications: None reported.
• Allergies: No allergies reported
• Reproductive Hx: Patient is an adolescent boy in middle school born full term.
ROS:
• GENERAL: The patient denies any pain, chills, fever, or weakness.
• HEENT: Patient reports no visual problems, blurring, or eye discomfort. The patient exhibits no epistaxis, nasal congestion, tinnitus, or ear discharge. He denies any sore throat or swallowing issues.
• SKIN: The patient denies any rash, wounds, itching or skin changes.
• CARDIOVASCULAR: He denies any chest pain, heart palpitations, or dizziness
• RESPIRATORY: He denies any cough, shortness of breath or dyspnea on exertion.
• GASTROINTESTINAL: He reports poor appetite, denies any abdominal pain, nausea, vomiting, diarrhea, or hematochezia
• GENITOURINARY: Denies urinary frequency, urgency, dysuria, or hematuria.
• NEUROLOGICAL: He denies any headaches, numbness, tingling or dizziness
• MUSCULOSKELETAL: Patient denies any musculoskeletal pain, or weakness. He can move all extremities.
• HEMATOLOGIC: He denies any bleeding or bruising easily
• LYMPHATICS: He denies any swellings
• ENDOCRINOLOGIC: Denies any heat or cold sensitivity.
Objective:
Vitals: BP-110/60, HR-88, RR-16, T-98.4, SPO2-99%, Weight-51 kg, Height-60 in
Physical Assessment
General: The patient appears feeble, but there are no outward indications of discomfort
GASTROINTESTINAL: Abdomen soft, nontender, nondistended, positive bowel sounds
NEUROLOGICAL: Patient is alert and oriented to person, place, and time.
Diagnostic results:
Hamilton depression scale- 9 (Mild depression)
Normal brain MRI and CT scans were performed to assess the presence of brain tumors or lesions that may impact cognitive function.
The Yale-Brown Obsessive -Compulsive Scale self-report -10 (mild symptoms)
ADHD rating scale score- 3 (severe symptoms).
Assessment:
Mental Status Examination: C.Q is an African American boy who is 12 years old and comes in with his mother for an initial evaluation and treatment. During the visit, the patient was clean and properly dressed. He was alert and knew his name, where he was, and what time it was. He did not have good eye contact, and his focus and attention were all over the books displayed in the room during the visit. He was repeating words, and it was hard for him to understand some of the questions being asked. He moved around a lot in his chair and couldn’t pay attention during the meeting. When his mother talked about some of the symptoms he shows at home, he said they were not true most of the time. He denies having any delusions, hallucinations, suicidal or homicidal thoughts or ideas.
Diagnostic Impression:

1. Inattentive Attention deficit hyperactivity disorder (ADHD): F90.0
   ADHD, also known as attention-deficit/hyperactivity disorder, is a prevalent psychiatric problem in children. Some of the symptoms displayed by persons with ADHD include difficulty concentrating, excessive restlessness, and impulsive behavior (Parekh, 2017). Inattentive ADHD is characterized by chronic inattention and/or hyperactivity-impulsivity that hinders functioning or growth. To diagnose this condition in children under 16, at least six symptoms of inattention must have been present for a minimum of six months and must be inappropriate for their developmental stage. These individuals frequently overlook details or make careless mistakes in school, work, or other activities. They struggle to concentrate on tasks or play, often disregarding direct instructions. They have a lack of attention and struggle to complete academic, household, and work-related tasks. Coordinating duties and activities poses a challenge for them. They may exhibit avoidance, dislike, or unwillingness to complete long-term mental tasks such as schoolwork. They frequently misplace items and are easily distracted, having trouble in remembering everyday tasks (Centers for Disease Control and Prevention, 2022). This is a crucial diagnosis for C.Q since he displayed these symptoms consistently both at school and home for a duration exceeding 6 months.
2. Obsessive Compulsive Disorder (OCD): F42.2
   Individuals afflicted with obsessive-compulsive disorder (OCD) experience intrusive and repetitive thoughts, ideas, or sensations known as obsessions. These obsessions then trigger the need to engage in ritualistic actions, referred to as compulsions. The recurrent behaviors that an individual does, such as handwashing, item checking, or cleaning, can significantly hinder both their daily functioning and their social interactions with others (Geller, 2022). Many individuals who do not have OCD nonetheless have distressing thoughts or engage in repetitive behaviors that do not disrupt their everyday functioning. Individuals diagnosed with OCD exhibit enduring and intrusive thoughts, along with repetitive and ritualistic behaviors. When they are unable to perform these activities regularly, it leads to significant anxiety, often linked to a specific fear of negative consequences for themselves or their loved ones if the actions are not completed (Geller, 2022). According to Geller (2022), a diagnosis of Obsessive-Compulsive Disorder (OCD) is given when a person experiences persistent and distressing obsessions and/or compulsions that continue for at least one hour per day, significantly impair their ability to perform in work or social settings. This diagnosis is also applicable to C.Q, as he displayed repetitive hand-washing habits daily, believing that there are germs everywhere. Even after bathing, he persists in washing his hands. He becomes protective against his father when his ritualistic behavior is brought up in treatment.
3. Obsessive Compulsive personality Disorder (OCPD): F60.5
   Obsessive-compulsive personality disorder (OCPD) is a chronic illness defined by an unhealthy pattern of extreme perfectionism, preoccupation with orderliness and small details, and a strong need to control one’s environment (Pinto et al., 2022). This is a common personality condition that affects a significant portion of the population. The symptoms of this disease are associated with significant difficulties in functioning in several areas of life, including work, school, social interactions, and leisure activities. Difficulties emerge when individuals want perfection and squander time on trivial tasks. Individuals diagnosed with Obsessive-Compulsive Personality Disorder (OCPD) are frequently characterized as exhibiting authoritarian tendencies and having excessively high expectations of their loved ones and colleagues (Pinto et al., 2022).
   Reflections:
   Families with children with mental illness go through a lot. ADHD is a long-term mental illness that needs to be treated properly. Unfortunately, ADHD can put a lot of strain on families’ finances (Ojinna et al., 2022). A lot of people don’t get the medical care they need because it costs too much. Promoting quick access to high-quality healthcare services is a top goal of the Healthy People 2030 program. As an upcoming PMHNP, I will always seek to help my patients if they do not have insurance and help them get it. This can make it easier for people like C.Q. and his parents to pay for his treatments. Mental illnesses affect people of all ages, races, and all ethnicities, but minorities are more likely than others to have them (Healthy People 2030, 2020). The recommended treatment plan is appropriate, at this time and the patient will continue with his weekly therapy and medications to assess his progress and make any changes with his pharmacological treatments when needed.
   Case Formulation and Treatment Plan:
   C.Q.’s mother is seeking psychiatric care for her son in response to the actions that he has displayed. C.Q. was born at full term, was a typical child, and performed quite well in school up until three years ago, when mom began to see some unusual behaviors in him. It was reported by the mother that he began to lose attention whenever he was asked to accomplish anything, including his schoolwork, which eventually influenced his grades. Another ritualistic habit that he acquired was washing his hands repeatedly within a period. This conduct has also been a source of great concern for his parents, even though he continued to refute the fact that his activity was not repetitious, even though it has become a routine for him.
   The treatment plan for C.Q. will consist of beginning an individual therapy treatment using the cognitive behavior therapy (CBT) technique. The goal of this treatment is to encourage the development of a daily structure with him, reducing his compulsiveness to wash his hands when it is not necessary, assisting him in reducing the number of arguments he has with his mother, and encouraging him to pay attention to the beginning and ending of tasks. Cognitive behavioral therapy is beneficial for children who have attention-deficit/hyperactivity disorder (ADHD) when it is supplied with the tools that are necessary for them to better regulate their emotions and impulses, which in turn helps with organization and the completion of activities (Ojinna et al., 1992). For assisting C.Q. in organizing and completing his schoolwork and responsibilities at home, one of the tools that was suggested to his parents was the provision of a planner for C.Q. to remind him of his daily tasks. During the therapeutic session, which will take place once per week for a period of six months, an assessment will be carried out to decide whether additional treatment sessions will be required. We will work along with his instructors and the school psychologist to find concessions that would allow C.Q. to be accepted into the individualized education program (IEP) so that he could be successful in school. In addition, the patient will begin receiving psychoeducation, as well as the administration of Adderall XR 10 mg by mouth daily and hydroxyzine 5 mg by mouth at bedtime, which will be administered as needed.
   Health Promotion: The patient would be assisted in recovering a normal quality of life both at home and at school by identifying appropriate health promotional services that would help him improve his symptoms and support him in regaining his standard of living. Examples includes the use of a planner to plan his tasks and remind him of what he is supposed to do at a particular time. We will also work alongside his instructors and psychologist to help enroll him into an IEP program to help him be successful in the classroom.
   Health Education: In the event of an emergency, the patient and his mother were instructed to call 911. They were educated on the importance of taking medications as prescribed. In addition, the crisis hotline and the national suicide prevention hotline phone numbers were also given to patient mother to have handy.
   Questions
4. How would you be able to differentiate between OCD and OCPD? What would be a factor as to how an OCD diagnosis is connected to the actions versus personality?
5. What other treatments would be recommended to this specific patient’s case? Would they be more beneficial than those already presented?
6. What education would you provide the parents or guardians who have children with such diagnoses? What advice would be given to ease the transition of a patient living with such

Post #2
Writer: M.T.S
Objectives:
By the end of the presentation, you will be able to:
• Identify the potential differential diagnoses for depression in older adults.
• Define the treatment goals for an older adult with depression.
• Learn about the unique considerations to take into account when creating a plan of care for older adults with depression.
• Develop a biopsychosocial model of illness for an older patient with depression.
Subjective:
CC: “I’m not depressed. It’s just that things have worsened since my dog died!”
HPI: The patient is an elderly female who presented for evaluation at the clinic. The patient has a history of anxiety since her husband died during the Pandemic. She has been living alone since then and reported doing “okay” in the company of her dog. However, the patient stated that “things have been worse” since the death of her dog four weeks ago. She said that she had been having a difficult time coping since the Covid-19 pandemic and began to be tearful. She revealed that she often cries but is adamant that she is not depressed. When asked whether she has ever struggled with similar feelings, she replied yes but mentioned that these feelings never lasted long. She stated she thought it was strange that she is often “tired” when thinking about things and has been unable to concentrate properly. She reported having difficulties falling asleep and when she falls asleep, she often wakes up after about 3 hours and takes a while to fall back asleep. The patient also stated that she had stopped doing what she used to enjoy such as puzzles because they remind her of her late husband. She endorsed feeling down most days and reported feeling that her energy had been drained away. The patient denied suicidal ideation, homicidal thoughts, or a history of self-injury.
Substance Current Use: The patient has never smoked and denied alcohol use, marijuana use, or other illicit substance use.
Medical History: Diverticulitis. Denied recent flare-ups.
Current Medications: Citrucel daily. Acetaminophen 1000mg daily PRN
Allergies: No known drug, food, or environmental allergies.
Reproductive Hx.: Has two estranged children.
ROS:
General: Reports slight fatigue. Denies weight loss, fever, weakness, or chills.
HEENT: Denies visual problems, hearing loss, congestion, or sore throat.
Skin: Denies rashes or lesions.
Cardiovascular: No chest pain, discomfort, or pressure. Denies palpitation or swelling in bilateral extremities.
Respiratory: No shortness of breath.
GI: Denies nausea, vomiting, diarrhea, constipation, or abdominal pain.
Neurological: Denies frequent headaches, dizziness, syncope, numbness, tingling, or a history of seizures. No changes in bowel and bladder control.
Musculoskeletal: Denies joint pain or swelling. Reports limited range of motion.
Hematologic: No history of anemia or bruising.
Endocrinologic: Denies heat/cold intolerance, polyuria, polydipsia, or polyphagia.
Objective:
Physical Exam:
Vital Signs: All within normal.
General: Alert and oriented x3. Appears well-groomed. Is not in apparent distress.
Diagnostic Results:
Two instruments were administered, the PHQ-9, GAD-7, and mini-mental state exam (MMSE). Her PHQ-9 score was 21, indicating severe depression. She scored 11 on the GAD-7, suggesting moderate anxiety. Her MMSE score of 23 indicates mild cognitive impairment.
Assessment:
Mental Status Exam: The patient is an elderly woman who appeared her age. She was well-groomed and appropriately dressed. The patient was cooperative and provided appropriate answers to the examiner’s questions. No abnormal motor movements or behaviors were noted during the interview. She spoke with a normal tone, rhythm, rate, and volume. Her self-reported mood was “feeling down” with appropriate affect as evidenced by multiple episodes of spontaneous crying. Her thought process was logical and coherent. Thought content was without delusions, visual or auditory hallucinations, obsessions and compulsions, suicidal ideation, or homicidal thoughts. Cognitively, she was alert and oriented x3. Her recent and remote memory was grossly intact. Her attention span was fair. Her insight was poor and her judgment was fair.
Differential Diagnosis:
Major Depressive Disorder(MDD): Depression is one of the most common mental health conditions affecting older adults (Devita et al., 2022). The DSM-5-TR identifies a cluster of typical symptoms of depression, which include a depressed mood, anhedonia, weight loss/gain, fatigue, hypersomnia/insomnia, psychomotor retardation/agitation, decreased concentration, suicidal thoughts, and feelings of worthlessness or guilt (American Psychiatric Association [APA], 2022). At least five of these symptoms must be present for at least two weeks to support the diagnosis of depression, with at least one of the symptoms being depressed mood or anhedonia. In the case presented, the patient endorsed feeling down, reported lack of interest in activities she used to enjoy, has been having sleep problems, difficulties concentrating, and psychomotor retardation characterized by being “tired” when thinking. These symptoms have caused significant distress to the extent the patient cries frequently. In the absence of other mental or medical problems, the patient meets the diagnostic criteria for depression.
Prolonged-Grief Disorder: This disorder is suspected given the patient’s revelation that she patient’s report that she has been having a difficult time coping after the death of her husband. The hallmark feature of prolonged grief disorder is persistent grief characterized by intense feelings of longing or yearning for the deceased and/or being preoccupied with thoughts and memories of the dead person (APA, 2022). People with prolonged grief disorder also display additional symptoms that may include avoidance of reminders, emotional pain, intense loneliness, and difficulties reintegrating back into society (APA, 2022). Although the patient reported avoiding playing puzzles because they remind her of her husband, she did not report having intense feelings of yearning for her husband or preoccupation with memories or thoughts involving her late husband. Therefore, she does not meet the diagnostic criteria for prolonged grief.
Generalized Anxiety Disorder (GAD): The patient’s history of anxiety and positive GAD-7 screen increases the likelihood that her symptoms might be due to GAD. The core feature of GAD is excessive, difficult-to-control worry about a range of domains related to day-to-day life that results in significant distress or marked impairment (APA, 2022). People with GAD also have a range of somatic, behavioral, and cognitive symptoms such as insomnia, restlessness, fatigue, problems with concentration, irritability, and muscle tension (Campbell-Sills & Brown, 2020). While the patient did endorse insomnia and trouble with concentration, her core complaints did not include excessive and difficult-to-control worry. Therefore, GAD is ruled out at this point.
Adjustment Disorder with depressed mood: The patient’s symptoms could also be explained by difficulty adjusting to the death of her dog. Adjustment disorders are characterized by the onset of emotional and/or behavioral symptoms after an encounter or exposure to a specific identical stressor (APA, 2022). The clinical features of adjustment disorders with depressed mood are notable distress that manifests as low mood, tearfulness, and/or feelings of hopelessness that are out of proportion and result in significant impairment in several areas of functioning (APA, 2022). However, the diagnosis of adjustment disorders is only made if these symptoms do not meet the criteria for another mental disorder or represent the worsening of an underlying or pre-existing disorder (APA, 2022). Since the patient’s symptoms met the criteria for depression, adjustment disorder is therefore ruled out.
Mild Cognitive Impairment (MCI) with depressed mood: MCI is described as a transitional stage between healthy aging and dementia and many patients with MCI after present with various features such as apathy, anxiety, and depression (Ma, 2020). The patient’s score of 23 on the MMSE suggests mild cognitive impairment. In the DSM-5-TR, MCI is characterized by a marked cognitive decline in one or more cognitive domains when compared to previous levels of performance. This decline can be based on the concern of the patient or that of a knowledgeable informant and evidence of notable impairment following standardized testing (APA, 2022). Although the patient’s MMSE indicated mild cognitive impairment, this could be due to normal aging. At the same time, cognitive impairment is common among older adults with depression and thus the mild MCI could be due to depression. All in all, additional cognitive tests will be needed.
Case Conceptualization & Treatment Plan
The patient’s primary diagnosis is major depressive disorder. Depression is a common mental illness affecting older adults, with epidemiological studies reporting that an average of 5.7% of older adults aged 60+ have depression. Depression across the lifespan is associated with a number of biopsychosocial factors that increase the person’s vulnerability to developing depression. The patient described experiencing a range of stressors and adverse life events that predisposed the patient to a greater risk of depression, including the death of her husband and the pandemic (Baker et al., 2021). Although the patient appears to have tried to cope with this event, she endorsed struggling emotionally since then. She reported frequent episodes of tearfulness and trouble with sleep, which could have been the prodromal period with subthreshold signs of depression (Dozois et al., 2020). The primary precipitating factor for depression in this patient was the death of her dog, which represents the loss of an important emotional support system (Devita et al., 2022). The loss of her dog pushed the patient to develop full-blown depression that has been sustained and maintained by the patient’s poor insight, declining cognitive functioning, poor resilience, limited/low emotional support from friends and family, and ongoing symptoms that perpetuate the cycle of depression.
Plan:
Psychotherapy: Initiate individual cognitive behavioral therapy (CBT). Older patients with moderate to severe depression should be started on high-intensity psychological interventions such as CBT (American Psychological Association, 2019; Baker et al., 2021; National Institute for Health Care Excellence[NICE], 2022). CBT is a goal-oriented intervention that focuses on resolving the presetting issues by focusing on the interaction between the patient’s thoughts, beliefs, attitudes, feelings, and behavior (NICE, 2022). CBT is an evidence-based and well-established intervention and would help the patient attain recovery through a range of techniques such as cognitive restructuring, behavioral activation, goal setting, and learning important coping skills delivered through different mechanisms (Bilbrey et al., 2022). Emphasis can be placed on behavioral activating and teaching her meaningful coping skills to allow her to develop resilience (Bilbrey et al., 2022).
CBT can be provided together with supportive therapy, which focuses on non-specific therapeutic aspects like facilitating the expression of emotions, highlighting successful experiences using the life-course approach, imparting optimism, and demonstrating empathy (Devita et al., 2022). The patient would benefit from this approach given her sense of loneliness.
Pharmacology: For pharmacologic treatment, the patient will be started on sertraline 25mg daily. Selective serotonin reuptake inhibitors (SSRIs)are the first-line medications for depression in older adults because of their favorable risk-benefit profile as well as better efficacy (Baker et al., 2021). Sertraline has a lower risk of interacting with other drugs and the patient’s starting dose of 25mg reflects the principle of starting slow with slow titration until the therapeutic dose is reached to minimize the risk of side effects (Baker et al., 2021). SSRIs are associated with a range of temporary side effects (headache, nausea, dry mouth, and gastric upset) commonly occurring in the first two weeks of starting the medication, and more serious adverse drug outcomes that include increased risk of stomach bleeding, sedation, and agitation.
Additional Test: Montreal Cognitive Assessment (MoCA) to evaluate the patient’s suspected MCI. MoCA provides a better prediction of cognitive impairment than MMSE (Pinto et al., 2019).
Referrals: None at this point.
Follow-up: RTC in 4 weeks. Parameters for follow-up include the patient’s progress as evidenced by her self-reported sense of improvement in symptoms and the presence/absence of medication side effects together with her ability to tolerate them. The patient’s preferences will strongly influence the possible modifications that can be made.
Social Determinants of Health
There are multiple social determinants of health to consider for this patient. This patient mentioned living alone and appears to have been relying on her dog for companionship. During the assessment, she mentioned that her only source of support was her cousin whom she talked with on the phone daily for about 30 minutes. The limited social support network is a significant determinant that may be contributing to her current symptoms and may affect her response to treatment. Her cultural beliefs related to depression are another social determinant that will shape her progress. Specifically, continued reluctance to acknowledge depression could point to negative beliefs about mental health and could lead to additional barriers to seeking help.
Health Promotion and Patient Education
Health promotion and patient education for this patient would aim to offer support, coping strategies, and resources to empower her in managing her mental health and overall health. Initial management of this patient should involve educating her about the appropriate sleep practices, the importance of regular exercise activity, and suitable self-care strategies to help improve her overall well-being (Baker et al.,2021). The specific self-care techniques that would be beneficial to this patient include relaxation techniques, stress management techniques, and age-appropriate activities to promote physical health. The tailored health promotion and patient education activities include the provision of grief-related support and education on depression. Educating the patient about grief and the grief response and linking her with local support resources such as self-help groups for seniors would help address potential subthreshold grief issues. Equally, educating this patient about depression, its symptoms, and how it can manifest differently in older adults can enable the patient to understand her condition. Part of this education should also center on educating the patient that having depression is okay and that seeking help for depression is not a sign of weakness.
Reflection Notes
If offered an opportunity to re-evaluate this patient, I would want to perform a comprehensive geriatric assessment, which entails a systematic approach to identifying both clinical and non-clinical problems and working collaboratively with interdisciplinary teams to coordinate the plan of care (Baker et al., 2021). This assessment would be crucial to identify additional issues affecting the patient and gain an opportunity to offer holistic care.
We have not completed any follow-up sessions with this patient. In the next follow-up session, which is scheduled 4 weeks after the initial session, the follow-up evaluation will focus on assessing the patient’s progress. Specifically, the follow-up assessment will entail asking the patient to provide her subjective opinion of any improvement in her symptoms, evaluate for potential side effects and how she is tolerating the medication, and share any additional issues that emerged over the four weeks. The outcomes of this assessment will inform the next course of action.
Questions

1. What labs/additional screening tests would be appropriate to have for this patient?
2. What additional criteria/information would you consider to rule out MCI occurring outside of depression?
3. What other alternative psychotherapy intervention(s) would you consider for this patient?
4. What are the possible protective factors that can be cultivated to support the patient’s treatment, management, and recovery?