Subjective:

CC: "So I work at this Engineering firm, and everything was great until they accelerated the deadlines, and I just can't concentrate"

HPI: HB is a 60-year-old Caucasian male who presents by himself to the clinic. He was referred to the clinic by his employer after he told his supervisor he was having problems concentrating at work. During the interview, H.B. admitted that he only seems to have a problem meeting the new deadlines set forth by his company. He believes that there has been added pressure to his daily tasks, making it difficult for him to concentrate. He feels that before the increased deadlines, he wasn't making simple mistakes like designing a window too small for an opening. He believes that before that, he had the time, and this prevented his errors. He admits there has been some form of this issue his whole life, even while attending school. He has always had trouble focusing and would find himself drifting off into space or thinking about things unrelated to the topic. Like for example, he stated, "In school,everyone would go to the library to cram for big exams" and "That was a normal thing. And, yeah,I'd go, but I'd end up looking out the window. Look, it's snowing, oh, it's springtime". He also stated during the interview that he has difficulties with his supervisor's lectures during a typical day at work. "We'd get together; it's groups." This isthe lecture by the department chief, who gets together with all the architects andengineers and discusses the day's mission. "What we're trying to work for, our goals". He stated that he has difficulty listening because his mind tends to wonder about something else, like "maybe my dog needs a bath. Orwhat am I going to have for lunch?" During the interview, H.B. also stated he finds it hard to stay organized. He has had multiple occasions where he has forgotten to pay his bills, and only after multiple threatening phone calls does he remember to act. He states he has made various attempts to get organized. His co-worker even bought him a calendar to write stuff down to do. He said that was great, except that he had never used it afterward.

Past Psychiatric History: Although he has had similar problems related to his current situation. He denies that he has ever been treated with medications or behavioral therapies as a child.

General Statement: HB has been very distracted during his life, especially while at work; he is unable to focus and appears disorganized. All these symptoms are affecting his productivity at work and at home. This case did not disclose pertinent information, and further assessment and interviewing are needed.

Caregivers (if applicable): currently, he lives by himself. He occasionally goes on some dates but there is nothing serious

Hospitalizations: There are no reports or evidence of having ever being hospitalized for psychiatric illness

Medication trials: There are no repots or evidence of having any medication trials.

Psychotherapy or Previous Psychiatric Diagnosis: There are no reports or evidence of knowledge during this assessment to suggest any previous diagnosis or therapy.

Substance Current Use and History: Per his statement, he occasionally indulges in having a drink, consisting of a scotch on the weekend with a cigar. He denies having any further history of binge drinking or drug use.

Family Psychiatric/Substance Use History: There are no reports or evidence from the assessment to show that this patient HB has a familiar history of psychiatric or substance use.

Psychosocial History: HB has a bachelor's degree in engineering. He lives alone, and he dates occasionally the opposite sex. Currently, there are no serious relationships in his life. He has never been married and has no children. He denies having any irritability or anger, he denies having concerns with his appetite. He states his focus and concentration are poor as he is easily distracted. He Denies concerns with his sleep and gets about 7 hours a night. He denies any legal issues

Medical History

• HTN,
• BPH,
• Angina,
• Hypertriglyceridemia

Current Medications:

• Cozaar 100mg daily,
• ASA 81mg po daily,
• Valsartan 80mg daily,
• Fenofibrate 160mg daily,
• Tamsulosin 0.4mg po bedtime.

Allergies:

• Dilaudid *Unknown reaction

Reproductive Hx:

• No children

ROS:

GENERAL:Harold Griffin is a 60-year-old white male, alert and oriented x 4, well-groomed and dressed in professional business attire, hyperverbal, but a good historian. He is not in any apparent distress during this assessment by the psychologist. He appears insightful and was restless and fidgety during this assessment. T- 98.8 P- 74 R 18 134/70 Ht 5'10 Wt 170lbs HEENT: Head- normocephalic, atraumatic, pupils equal and reactive to light, wearing glasses, bilateral pinna noted with no pain or discharge sinus tenderness nor oropharyngeal erythema. TMs-intact bilaterally without erythema or effusion, Neck-No thyromegaly, no carotid bruits, no masses, no tracheal deviation, supple with a full range of motion SKIN: intact, no lesions or rashes noted. Turgor is good, and no cyanosis, pallor or jaundice noted. No skin issues, no scars or rashes CARDIOVASCULAR: Appears slightly diaphoretic, no chest pain, pressure or discomfort, no palpitations, clubbing, no cyanosis RESPIRATORY: No shortness of breath, no rapid breathing, no cough or sputum GASTROINTESTINAL: Normal bowel sound x 4 quadrants, no anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood in his stool GENITOURINARY: Urinary retention, history of BPH, on medication NEUROLOGICAL: No history of head injuries, no confusion, headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control MUSCULOSKELETAL: No carpal nodules, no muscle, back pain, joint pain, or stiffness HEMATOLOGIC: No anemia, bleeding, or bruising, no purpura LYMPHATICS: No enlarged nodes. No history of splenectomy ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. Nopolyuria or polydipsia.

Objective:

Physical exam: if applicable

Diagnostic results:

• Montreal Cognitive Assessment (MoCA): MOCA 28/30 difficulty with attention and delayed recall. MoCA is scored on a 30-point scale, with items that assess delayed word recall (5 points), visuospatial/executive function (7 points; includes clock-drawing), language (6 points), attention/concentration (6 points), and orientation (6 points) This is a normal result since the cut off score for what is considered normal is 26.
• Adult ADHD self-report scale: ASRS-5 21/24. It consists of 18 items based on DSM-IV symptoms/criteria adapted to adults with ADHD, which are measured on a five-point scale (0 = never/seldom and 4 = very often. HB scored 21 out of 24 points, placing him in the often and very often categories.
• Diagnostic Interview for ADHD in adults (DIVA 2.0): This involves use of a structured diagnostic interview for ADHD in adults called the DIVA 2.0 and is considered the best basis of diagnosis.

Assessment: Mental Status Examination

HB is well-dressed and groomed. His speech is normal, and his eye contact is normal. However, it was observed that he is restless; he often fidgets and squirms around when explaining things in detail. His effect is full; his emotion is based on the situation presented. His mood is somewhat irritable since he is trying to figure out why he has all these problems. HB is oriented, with a memory and attention span that is very short. He easily gets distracted and switches focus frequently and unintentionally. His thoughts and perceptions appear to be normal, but his thought process is distractible. HB's behavior and psychomotor activity are hyper, with some restlessness, but he is cooperative. His speech and language are normal for his age and education. His insights and judgement are at normal state.

1. Examine the patient's mental status examination results. Provide three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis.

2. Explain the critical-thinking process that led to the primary diagnosis selected. Include pertinent positives and pertinent negatives for this 60 year old client.