NRNP 6675 Week 2 E M Patient Case Study 2022
Student Name College of Nursing-PMHNP, Walden University NRNP 6675: PMHNP Care Across the Lifespan II Faculty
... [Show More] Name Assignment Due Date Pathways Mental 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 Page | 1 Walden University, LLC 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 Page | 2 Walden University, LLC 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]
