Student Name
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II
Faculty Name
Assignment Due Date
Pathways Mental... [Show More] Health
PSYCHIATRIC PATIENT EVALUATION
INSTRUCTIO
NS
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
INFORMATIO
N
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, client denied symptoms of depression, denied anergia, anhedonia,
amotivation, no anxiety, denied frequent worry, reports feeling restlessness, no
reported panic symptoms, no reported obsessive/compulsive behaviors. 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, hard time
focusing and concentrating, affecting her job. Has low frustration tolerance,
sleeping 5–6 hrs/24hrs reports nightmares of previous rape, isolates, fearful to
go 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.
DIAGNOSTIC
SCREENING
RESULTS
Screen of symptoms in the past 2 weeks:
PHQ 9 = 0 with symptoms rated as no difficulty in functioning
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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
Interpreting the Total Score:
Total Score Interpretation ≥10 Possible diagnosis of GAD; confirm by further
evaluation 5 Mild Anxiety 10 Moderate anxiety 15 Severe anxiety
MDQ screen negative
PCL-5 Screen 32
PAST
PSYCHIATRIC
AND
SUBSTANCE
USE
TREATMENT
Entered mental health system when she was age 19 after 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
SUBSTANCE
USE HISTORY
Have you used/abused any of the following (include frequency/amt/last use):
Substance Y/N Frequency/Last Use
Tobacco products Y ½
ETOH Y last drink 2 weeks ago, reports
drinks 1-2 times monthly one
drink socially
Cannabis N
Cocaine Y last use 2015
Prescription stimulants Y last use 2015
Methamphetamine N
Inhalants N
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Sedative/sleeping pills N
Hallucinogens N
Street Opioids N
Prescription opioids N
Other: specify (spice, K2, bath
salts, etc.)
Y reports one-time ecstasy use in
2015
Any history of substance related:
Blackouts: +
Tremors: -
DUI: -
D/T's: -
Seizures: -
Longest sobriety reported since 2015—stayed sober maintaining sponsor,
sober friends, and meetings
PSYCHOSOCI
AL HISTORY
Client was raised by adoptive parents since age 6; from Russian orphanage.
She has unknown siblings. She is single; has no children.
Employed at local tanning bed salon
Education: High School Diploma
Denied current legal issues.
SUICIDE /
HOMICIDE
RISK
ASSESSMENT
RISK FACTORS FOR SUICIDE:
Suicidal Ideas or plans - no
Suicide gestures in past - no
Psychiatric diagnosis - yes
Physical Illness (chronic, medical) - no
Childhood trauma - yes
Cognition not intact - no
Support system - yes
Unemployment - no
Stressful life events - yes
Physical abuse - yes
Sexual abuse - yes
Family history of suicide - unknown
Family history of mental illness - unknown
Hopelessness - no
Gender - female
Marital status - sing [Show Less]
