LECTPEREZ
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan
II Faculty Name
Assignment Due Date
WAlden University, LLC
This study source was downloaded by 100000843746907 from CourseHero.com on 04-07-2022 17:28:02 GMT -05:00
https://www.coursehero.com/file/123098268/case-scenario-1docx/
, 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 Identification was verified by stating of their name and date of birth.
INFORMATION
Time spent for evaluation: 0900am-0957am
CHIEF “My other provider retired. I don’t think I’m doing so well.”
COMPLAINT
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
Screen of symptoms in the past 2 weeks:
SCREENING
RESULTS
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
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
Page | 1 Walden University, LLC
This study source was downloaded by 100000843746907 from CourseHero.com on 04-07-2022 17:28:02 GMT -05:00
https://www.coursehero.com/file/123098268/case-scenario-1docx/
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan
II Faculty Name
Assignment Due Date
WAlden University, LLC
This study source was downloaded by 100000843746907 from CourseHero.com on 04-07-2022 17:28:02 GMT -05:00
https://www.coursehero.com/file/123098268/case-scenario-1docx/
, 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 Identification was verified by stating of their name and date of birth.
INFORMATION
Time spent for evaluation: 0900am-0957am
CHIEF “My other provider retired. I don’t think I’m doing so well.”
COMPLAINT
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
Screen of symptoms in the past 2 weeks:
SCREENING
RESULTS
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
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
Page | 1 Walden University, LLC
This study source was downloaded by 100000843746907 from CourseHero.com on 04-07-2022 17:28:02 GMT -05:00
https://www.coursehero.com/file/123098268/case-scenario-1docx/
