Student Name College 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, 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  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 (wor.

1. Student Name
College 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

2. 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

3. behaviors.
DIAGNOSTIC SCREENING RESULTS
Screen of symptoms in the past 2 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
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•

4. 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

5. Cocaine
Y
last use 2015
Prescription stimulants
Y
last use 2015
Methamphetamine
N
Inhalants
N
Sedative/sleeping pills
N
Hallucinogens
N
Street Opioids
N
Prescription opioids
N

6. 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
PSYCHOSOCIAL 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 - single•

7. White race• Access to means• Substance abuse - in remission
PROTECTIVE FACTORS FOR SUICIDE:
• Absence of psychosis - yes• Access to adequate health care -
yes• Advice & help seeking - yes• Resourcefulness/Survival
skills - yes• Children - no• Sense of responsibility - yes•
Pregnancy - no; last menses one week ago, has Norplant•
Spirituality - yes• Life satisfaction - “fair amount”• Positive
coping skills - yes• Positive social support - yes• Positive
therapeutic relationship - yes• Future oriented - yes
Suicide Inquiry: Denies active suicidal ideations, intentions, or
plans. Denies recent self-harm behavior. Talks futuristically.
Denied history of suicidal/homicidal ideation/gestures; denied
history of self-mutilation behaviors
Global Suicide Risk Assessment: The client is found to be at
low risk of suicide or violence, however, risk of lethality
increased under context of drugs/alcohol.
No required SAFETY PLAN related to low risk
MENTAL STATUS EXAMINATION
She is a 25 yo Russian female who looks her stated age. She is
cooperative with examiner. She is neatly groomed and clean,
dressed appropriately. There is mild psychomotor restlessness.
Her speech is clear, coherent, normal in volume and tone, has
strong cultural accent. Her thought process is ruminative. There
is no evidence of looseness of association or flight of ideas. Her
mood is anxious, mildly irritable, and her affect appropriate to
her mood. She was smiling at times in an appropriate manner.
She denies any auditory or visual hallucinations. There is no
evidence of any delusional thinking. She denies any current
suicidal or homicidal ideation. Cognitively, She is alert and

8. oriented to all spheres. Her recent and remote memory is intact.
Her concentration is fair. Her insight is good.
CLINICAL IMPRESSION
Client is a 25 yo Russian female who presents with history of
treatment for PTSD, ADHD, Stimulant use Disorder, in
remission.
Moods are anxious and irritable. She has ongoing reported
symptoms of re-experiencing, avoidance, and hyperarousal of
her past trauma experiences; ongoing subsyndromal symptoms
related to her past ADHD diagnosis and exacerbated by her
PTSD diagnosis. She denied vegetative symptoms of depression,
no evident mania/hypomania, no psychosis, denied anxiety
symptoms. Denied current cravings for drugs/alcohol, exhibits
no withdrawal symptoms, has somatic concerns of GI upset and
headaches.
At the time of disposition, the client adamantly denies SI/HI
ideations, plans or intent and has the ability to determine right
from wrong, and can anticipate the potential consequences of
behaviors and actions. She is a low risk for self-harm based on
her current clinical presentation and her risk and protective
factors.
DIAGNOSTIC IMPRESSION
[STUDENT TO PROVIDE DSM-5 AND ICD-10 CODING]
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TREATMENT PLAN
1) Medication: • Increase fluoxetine 40mg po daily for PTSD

9. #30 1 RF• Continue with atomoxetine 80mg po daily for ADHD.
#30 1 RF
Instructed to call and report any adverse reactions.
Future Plan: monitor for decrease re-experiencing,
hyperarousal, and avoidance symptoms; monitor for improved
concentration, less mistakes, less forgetful
2) Education: Risks and benefits of medications are discussed
including non-treatment. Potential side effects of medications
discussed. Verbal informed consent obtained.
Not to drive or operate dangerous machinery if feeling sedated.
Not to stop medication abruptly without discussing with
providers.
Discussed risks of mixing medications with OTC drugs, herbal,
alcohol/illegal drugs. Instructed to avoid this practice. Praised
and Encouraged ongoing abstinence. Maintain support system,
sponsors, and meetings.
Discussed how drugs/ETOH affects mental health, physical
health, sleep architecture.
3) Patient was educated about therapy and services of the MHC
including emergent care. Referral was sent via email to therapy
team for PET treatment.

10. 4) Patient has emergency numbers: Emergency Services 911, the
national Crisis Line 800-273-TALK, the MHC Crisis Clinic.
Patient was instructed to go to nearest ER or call 911 if they
become actively suicidal and/or homicidal.
5) Time allowed for questions and answers provided. Provided
supportive listening. Patient appeared to understand discussion
and appears to have capacity for decision making via verbal
conversation.
6) RTC in 30 days
7) Follow up with PCP for GI upset and headaches, reviewed
PCP history and physical dated one week ago and include lab
results
Patient is amenable with this plan and agrees to follow
treatment regimen as discussed.
NARRATIVE ANSWERS
[IN 1-2 PAGES, ADDRESS THE FOLLOWING:
•
EXPLAIN WHAT PERTINENT INFORMATION,
GENERALLY, IS REQUIRED IN DOCUMENTATION TO
SUPPORT DSM-5 AND ICD-10 CODING.•
EXPLAIN WHAT PERTINENT DOCUMENTATION IS
MISSING FROM THE CASE SCENARIO, AND WHAT OTHER
INFORMATION WOULD BE HELPFUL TO NARROW YOUR
CODING AND BILLING OPTIONS.•
FINALLY, EXPLAIN HOW TO IMPROVE DOCUMENTATION

11. TO SUPPORT CODING AND BILLING FOR MAXIMUM
REIMBURSEMENT.]
Add your answers here. Delete instructions and placeholder text
when you add your answers.
REFERENCES
[ADD APA-FORMATTED CITATIONS FOR ANY SOURCES
YOU REFERENCED]
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citations.
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