| Student NameCollege of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II Faculty Name Assignment Due Date |
Pathways Mental Health
Psychiatric Patient Evaluation
|
Instructions |
Use the following case template to complete Week 2 Assignment 1. On page 5, assign DSM-5 and ICD-10 codes to the services documented. You will add your narrative answers to the assignment questions to the bottom of this template and submit altogether as one document. | ||
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Identifying Information |
Identification was verified by stating of their name and date of birth.Time spent for evaluation: 0900am-0957am | ||
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Chief Complaint |
“My other provider retired. I don’t think I’m doing so well.” | ||
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HPI |
25 yo Russian female evaluated for psychiatric evaluation referred from her retiring practitioner for PTSD, ADHD, Stimulant Use Disorder, in remission. She is currently prescribed fluoxetine 20mg PO daily for PTSD, atomoxetine 80mg PO daily for ADHD.Today, the client denied symptoms of depression, anergia, anhedonia, amotivation, no anxiety, denied frequent worry, reports feeling restlessness, no reported panic symptoms, and no reported obsessive/compulsive behaviors. The client denies active SI/HI ideations, plans or intent. There is no evidence of psychosis or delusional thinking. | ||
Evaluation and Management E/M NRNP 6675
| WAlden University, LLC |
| Student NameCollege of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II Faculty Name Assignment Due Date |
Pathways Mental Health
Psychiatric Patient Evaluation
|
Instructions |
Use the following case template to complete Week 2 Assignment 1. On page 5, assign DSM-5 and ICD-10 codes to the services documented. You will add your narrative answers to the assignment questions to the bottom of this template and submit altogether as one document. | ||
|
Identifying Information |
Identification was verified by stating of their name and date of birth.Time spent for evaluation: 0900am-0957am | ||
|
Chief Complaint |
“My other provider retired. I don’t think I’m doing so well.” | ||
|
HPI |
25 yo Russian female evaluated for psychiatric evaluation referred from her retiring practitioner for PTSD, ADHD, Stimulant Use Disorder, in remission. She is currently prescribed fluoxetine 20mg PO daily for PTSD, atomoxetine 80mg PO daily for ADHD.Today, the client denied symptoms of depression, anergia, anhedonia, amotivation, no anxiety, denied frequent worry, reports feeling restlessness, no reported panic symptoms, and no reported obsessive/compulsive behaviors. The client denies active SI/HI ideations, plans or intent. There is no evidence of psychosis or delusional thinking.
Client denied past episodes of hypomania, hyperactivity, erratic/excessive spending, involvement in dangerous activities, self-inflated ego, grandiosity, or promiscuity. Client reports increased irritability and easily frustrated, loses things easily, makes mistakes, and has a hard time focusing and concentrating, affecting her job. Has low frustration tolerance, sleeping 5–6 hrs/24hrs reports nightmares of a previous rape, isolates, fearful of going outside, has missed several days of work, appetite decreased. She has somatic concerns with GI upset and headaches. Client denied any current binging/purging behaviors, denied withholding food from self, or engaging in anorexic behaviors. No self-mutilation behaviors. |
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Diagnostic Screening Results |
Screening of symptoms in the past two weeks:PHQ 9= 0 with symptoms rated as no difficulty in functioning Interpretation of Total Score Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression
GAD 7= 2 with symptoms rated as no difficulty in functioning MDQ screen negative PCL-5 Screen 32 |
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Past Psychiatric and Substance Use Treatment |
· Entered mental health system when she was age 19 after being raped by a stranger during a house burglary.· Previous Psychiatric Hospitalizations: denied
· Previous Detox/Residential treatments: one for abuse of stimulants and cocaine in 2015 · Previous psychotropic medication trials: sertraline (became suicidal), trazodone (worsened nightmares), bupropion (became suicidal), Adderall (began abusing) · Previous mental health diagnosis per client/medical record: GAD, Unspecified Trauma, PTSD, Stimulant use disorder, ADHD confirmed by school records Online class and exam helpStruggling with online classes or exams? Get expert help to ace your coursework, assignments, and tests stress-free! | ||