course material

1. [From 10$/Pg] Lifespan Ii Faculty Name
[From 10$/Pg] Lifespan Ii Faculty Name WAlden University, LLC Student
NameCollege of Nursing-PMHNP, Walden UniversityNRNP 6675: PMHNP Care Across
the Lifespan IIFaculty NameAssignment Due Date Pathways Mental Health Psychiatric
Patient Evaluation InstructionsUse 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 InformationIdentification
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.” HPI25 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 ResultsScreen
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

2. 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 HistoryHave
you used/abused any of the following (include frequency/amt/last
use): SubstanceY/NFrequency/Last Use Tobacco productsY½ ETOHYlast drink 2
weeks ago, reports drinks 1-2 times monthly one drink socially CannabisN CocaineYlast
use 2015 Prescription stimulantsYlast
use 2015 MethamphetamineN InhalantsN Sedative/sleeping pillsN HallucinogensN St
reet OpioidsN Prescription opioidsN Other: specify (spice, K2, bath salts,
etc.)Yreports one-time ecstasy use in 2015Any 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
HistoryClient 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
salonEducation: High School DiplomaDenied current legal issues. Suicide / HOmicide
Risk AssessmentRISK 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· White race· Access to means· Substance abuse – in
remissionPROTECTIVE 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 – yesSuicide 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 behaviorsGlobal 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 ExaminationShe
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 oriented

3. to all spheres. Her recent and remote memory is intact. Her concentration is fair. Her
insight is good. Clinical ImpressionClient 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]Double click inside this text box to add/edit
text. Delete placeholder text when you add your answers. Treatment Plan1) Medication: ·
Increase fluoxetine 40mg po daily for PTSD #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 forgetful2) 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.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 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

4. any sources you referenced]Delete instructions and placeholder text when you add your
citations.