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WAlden University, LLC
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Student Name
College of ??????Nursing-PMHNP, Walden University
NRNP 6675: ??????PMHNP Care Across the Lifespan II
Faculty Name
Assignment ??????Due Date?
?Pathways Mental Health?
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Psychiatric Patient Evaluation
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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.
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Identifying Information
Identification was verified by stating of their name and ????date of birth.
Time spent for evaluation: 0900am-0957am
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Chief Complaint
?My other provider retired. I don?t think I?m doing so ????well.?
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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.
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????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.?
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Diagnostic Screening Results
Screen of symptoms in the past 2 weeks:
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????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
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????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
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????MDQ screen negative
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????PCL-5 Screen 32
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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
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Substance Use History
Have you used/abused any of the ????following (include frequency/amt/last use):
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Substance
Y/N
Frequency/Last Use
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Tobacco ??????products
Y
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ETOH
Y
last ??????drink 2 weeks ago, reports drinks 1-2 times monthly one drink ??????socially?
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Cannabis
N
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Cocaine
Y
last use ??????2015
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Prescription ??????stimulants
Y
last use ??????2015
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Methamphetamine
N
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Inhalants
N
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Sedative/sleeping ??????pills
N
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Hallucinogens
N
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Street ??????Opioids
N
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Prescription ??????opioids
N
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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
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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.
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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
? 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
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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 oriented to ????all spheres. Her recent and remote memory is intact. Her concentration is ????fair. Her insight is good.?
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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.?
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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.
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Treatment Plan
1) Medication:?
? Increase fluoxetine 40mg po daily for PTSD ????#30 1 RF
? Continue with atomoxetine 80mg po daily for ????ADHD. #30 1 RF
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????Instructed to call and report any adverse reactions.
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????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.
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????Not to drive or operate dangerous machinery if feeling sedated.
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????Not to stop medication abruptly without discussing with providers.
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????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.
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????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
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Patient is amenable with this plan and agrees to ????follow treatment regimen as discussed.?
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Narrative Answers
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[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.
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References
[Add APA-formatted citations for any sources you referenced]
Delete instructions and placeholder text when you add your citations.
