Neurocognitive Case Study
The client H.B is a 60yo male who presented to the clinic with difficulty in paying attention while doing his work, which started during his school days. H.B reported that he could look out through the library window when other students were busy cramming for an exam and start thinking about the weather. While studying, the client was disrupted by the slightest thing, including whispers. He could only concentrate in a location with zero disruptions. The client added that he could easily switch off during lectures. While the lecturer and other students were discussing goals to be achieved, he could switch his mind and start thinking that his dog needs a bath, what he would take for lunch, or anything else outside what was being taught. The client also revealed an increased tendency to make silly mistakes at his workplace. In one incident, the client drew the window opening way too small. The client claims that these symptoms started following the introduction of tight deadlines. He also reports an inability to meet accelerated deadlines at his workplace. However, his colleagues are comfortable with the tight deadlines. Furthermore, the client reports doing tasks incorrectly at his workplace and they end up being reassigned to his colleagues, getting him in a lot of trouble with the management. He also reveals being disorganized both at home and workplace. He easily forgets where he kept his items, including shoes, socks, phone, and jacket. He started marking all important dates and events on a calendar that his colleague bought him as a way of motivating him. Nonetheless, the client considers writing down a waste of time since he does not look at the calendar. The client also forgets to pay bills. get paid. He pays his bills with penalties after receiving threatening letters or calls. H. B reports hyperactivity and gets uncomfortable with the chair within a short duration. In school, he could not remain focused. During childhood, caffeine and sugar increased his hyperactivity, making him climb the walls. Nowadays caffeine helps him remain focused. The client reports sleeping for 7 hours per night. He reports that his appetite is good. Denied legal issues;
Past Psychiatric History:
- General Statement: I am having difficulty with attention and delayed recall.
- Caregivers (if applicable): Not applicable
- Hospitalizations: Denies hospitalization history.
- Medication trials: Denies being involved in a medication trial.
- Psychotherapy or Previous Psychiatric Diagnosis: Denies receiving medications or behavioral therapies for ADHD.
Substance Current Use and History: Takes one scotch drink over the weekends. He also takes a cigar. The client takes coffee to remain focused for some time.
Family Psychiatric/Substance Use History Denies history of psychiatric disorders or substance use among family members.
Psychosocial History: The client works at a large architectural engineering firm with accelerated deadlines. Takes one scotch drink over the weekends. He also takes a cigar. The client has never married and does not have any children. He dates casually.
- Current Medications:
- Cozaar 100mg daily taken to control hypertension.
- ASA 81mg po daily taken to manage angina.
- Valsartan 80mg daily for managing Angina
- Fenofibrate 160mg daily for managing hypertriglyceridemia.
- Tamsulosin 0.4mg po bedtime taken to manage BPH
- Allergies: Dilaudid
- Reproductive Hx: Has no children
- GENERAL: Denies weakness, fever, or fatigue.
- HEENT: The client denies head trauma or headache. He denies eye dryness, visual loss, or eye discharge. He denies ear discharge, loss of hearing, or ear pain. He denies nasal blockage, difficulty with smell, or running nose. He denies difficulty with smell or swallowing.
- SKIN: Denies rashes or dryness.
- CARDIOVASCULAR: Denies nocturnal orthopnea or chest discomfort.
- RESPIRATORY: Denies sputum production, coughing, or irregular breathing rate.
- GASTROINTESTINAL: Denies nausea or vomiting.
- GENITOURINARY: Denies frequent urination.
- NEUROLOGICAL: Reports difficulty with attention and delayed recall.
- MUSCULOSKELETAL: Denies back pain or muscle stiffness.
- HEMATOLOGIC: Denies excessive bleeding.
- LYMPHATICS: Denies swelling of the lymph nodes.
- ENDOCRINOLOGIC: Reports good appetite. Denies heat or cold intolerance.
- PSYCHIATRY: Denies insomnia and suicidal thoughts.
Vitals: T 98.8°F; Pulse 74; BP 134/70; RR: 18; Weight 170lbs, and Height 5’10”
General: The client is a 60yo male who presented to the psychiatric clinic. The client is well-nourished, presentable, and smartly dressed. He is attentive throughout the clinical interview and answers all questions correctly. He maintains eye contact and upright posture during the interview. However, he is easily disrupted and tends to move from one side of the chair to another. His self-reported mood is “Good.” The client does not seem to be in acute distress. He speaks in a low tone and clear voice. His affect and judgment are good. He is alert and oriented to places, persons, events, and situations. He is future-oriented. He denies suicidal thoughts or ideations. He depicts strong thought processes
HEENT: No lesions or head trauma. Accommodation of the pupils is at 3mm bilaterally. No abnormalities were noted on the ears. The landmarks are identifiable. The nose has no external lesions. No nasal drainage. Mouth, gum, or lip ulcers absent. No bleeding gums.
Neck: The neck and shoulders are flexible.
CV: S1 and S2 present with no gallops.
Lungs: Lungs have no tenderness. Lungs are clear to auscultation.
ABD: Non–tender and large abdomen with no masses.
PV: No clubbing noted.
MSK: Normal gait and station.
Neuro: Bilateral strong and equal hand grip.
Psych: Appears to be in acute distress and hyperactive.
Mental Status Examination:
- MOCA 28/30 difficulty with attention and delayed recall;
- ASRS-5 21/24
- Vascular dementia (VaD) – Primary diagnosis
- Attention deficit hyperactivity disorder (ADHD)
- Alzheimer’s disease (AD)
- Frontotemporal dementia (FTD)
Vascular Dementia (VaD)
Vascular Dementia is the primary diagnosis for this client. This condition is characterized by trouble with memory, slowed thinking, difficulty with organization and solving complex problems, or being easily distracted (Zheng et al., 2019). Additionally, individuals with this condition experience mood or behavior changes, including irritability, depression, or loss of interest. The client qualifies for this diagnosis since she reported difficulty with attention and delayed memory. The client also reported being disorganized and forgetting where he kept his item. He is slow in completing assigned tasks at his workplace, delaying meeting the deadline. Stroke and hypertension are significant risk factors for vascular dementia (VaD). Having a history of hypertension the client is at a high risk of VaD. Therefore, Vascular Dementia qualifies as the primary diagnosis for this client.
Attention Deficit Hyperactivity Disorder (ADHD)
The client also qualifies for an ADHD diagnosis. ADHD is a neurodevelopmental disorder characterized by various symptoms, including excessive amounts of inattention, being unable to sit still, hyperactivity, impulsivity, irritability, absent-mindedness, difficulty focusing, forgetfulness, short attention span, or problem paying attention (Mukherjee et al., 2022). The client might have this disorder since he reported difficulty with attention, hyperactivity, irritability, absent-mindedness, difficulty focusing, forgetfulness, and short attention span. However, ADHD was ruled out due to the absence of significant symptoms, including impulsivity and irritability.
Alzheimer’s Disease (AD)
AD is another potential diagnosis for this client. It is characterized by confusion and increased memory loss, inability to learn new things, the problem with reading and difficulty with language, inability to organize thoughts or think logically, shortened attention span, and challenges in coping with new situations (Folch et al., 2018). The client qualifies for this diagnosis since he reported difficulty with attention and delayed memory. However, this condition is ruled out due to the absence of significant symptoms, including confusion, the problem with reading and difficulty with language, inability to organize thoughts or think logically, and challenges in coping with new situations.
Frontotemporal Dementia (FTD)
FTD is the last differential diagnosis for this client. This condition is characterized by language problems, getting distracted easily, and organization and planning difficulties (Young et al., 2018). The client qualifies for this diagnosis since he reported getting distracted easily and having difficulty organizing her personal properties. However, this condition was ruled out due to the absence of language problems.
I agree with the preceptor’s assessment and diagnostic impression of this client. The presented clinical manifestations, including being easily disrupted and short attention span characterize Vascular dementia (VaD). Additionally, the client’s Montreal Cognitive Assessment (MoCA) score was 28/30, indicating difficulty with attention and delayed recall. From this case, I learned that differential diagnosis should be conducted to rule out other neurocognitive disorders with overlapping disorders. If I was treating this client again, I would gather more health-related information to guide me in making an appropriate diagnosis for this client. Furthermore, legal/ethical considerations should be considered in treating this patient. By adhering to the ethical principles of beneficence, mental healthcare providers will use their knowledge and skills to benefit the client, through quality healthcare services. Lastly, the treatment plan should target health promotion and disease prevention. The client has a history of hypertension, increasing the risk of heart disease and stroke (Fuchs & Whelton, 2020). Thus, the client should focus on lifestyle modification to reduce the risk of other health conditions related to hypertension.
Folch, J., Ettcheto, M., Petrov, D., Abad, S., Pedrós, I., Marin, M., … & Camins, A. (2018). Review of the advances in treatment for Alzheimer’s disease: strategies for combating β-amyloid protein. Neurología (English Edition), 33(1), 47-58. DOI:10.33582/2637-4927/1002.
Fuchs, F. D., & Whelton, P. K. (2020). High blood pressure and cardiovascular disease. Hypertension, 75(2), 285-292. https://doi.org/10.1161/HYPERTENSIONAHA.119.14240
Mukherjee, P., Vilgis, V., Rhoads, S., Chahal, R., Fassbender, C., Leibenluft, E., … & Schweitzer, J. B. (2022). Associations of Irritability With Functional Connectivity of Amygdala and Nucleus Accumbens in Adolescents and Young Adults With ADHD. Journal of attention disorders, 26(7), 1040-1050.
Young, J. J., Lavakumar, M., Tampi, D., Balachandran, S., & Tampi, R. R. (2018). Frontotemporal dementia: latest evidence and clinical implications. Therapeutic advances in psychopharmacology, 8(1), 33-48. doi: 10.1177/2045125317739818
Zheng, Y., Guo, H., Zhang, L., Wu, J., Li, Q., & Lv, F. (2019). Machine learning-based framework for differential diagnosis between vascular dementia and Alzheimer’s disease using structural MRI features. Frontiers in neurology, 10, 1097. https://doi.org/10. 3389/fneur.2019.01097