NRNP 6675 PMHNP Care Across the Life Span II: Evaluation and Management (E/M)

NRNP 6675 PMHNP Care Across the Life Span II Evaluation and Management (E/M)

Psychiatric Patient Evaluation

Instructions

Use the following case template to complete Week 2 Assignment 1. On page 5, assign DSM-5-TR and Updated 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

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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

NRNP 6675 PMHNP Care Across the Life Span II Evaluation and Management

· 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
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

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

· 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 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-TR and Updated ICD-10 coding]

Double click inside this text box to add/edit text. Delete placeholder text when you add your answers.

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

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.

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.

As we begin this session, I would like to take this opportunity to clarify my expectations for this course:

Please note that GCU Online weeks run from Thursday (Day 1) through Wednesday (Day 7).

Course Room Etiquette:

It is my expectation that all learners will respect the thoughts and ideas presented in the discussions.
All postings should be presented in a respectful, professional manner. Remember – different points of view add richness and depth to the course!

Office Hours:

My office hours vary so feel free to shoot me an email at [email protected] or my office phone is 602.639.6517 and I will get back to you within one business day or as soon as possible.
Phone appointments can be scheduled as well. Send me an email and the best time to call you, along with your phone number to make an appointment.
I welcome all inquiries and questions as we spend this term together. My preference is that everyone utilizes the Questions to Instructor forum. In the event your question is of a personal nature, please feel free to post in the Individual Questions for Instructor forumI will respond to all posts or emails within 24 or sooner.

Late Policy and Grading Policy

Discussion questions:

I do not mark off for late DQ’s.
I would rather you take the time to read the materials and respond to the DQ’s in a scholarly way, demonstrating your understanding of the materials.
I will not accept any DQ submissions after day 7, 11:59 PM (AZ Time) of the week.
Individual written assignments – due by 11:59 PM AZ Time Zone on the due dates indicated for each class deliverable.

Assignments:

Assignments turned in after their specified due dates are subject to a late penalty of -10%, each day late, of the available credit. Please refer to the student academic handbook and GCU policy.
Any activity or assignment submitted after the due date will be subject to GCU’s late policy
Extenuating circumstances may justify exceptions, which are at my sole discretion. If an extenuating circumstance should arise, please contact me privately as soon as possible.
No assignments can be accepted for grading after midnight on the final day of class.
All assignments will be graded in accordance with the Assignment Grading Rubrics

Participation

Participation in each week’s Discussion Board forum accounts for a large percentage of your final grade in this course.
Please review the Course Syllabus for a comprehensive overview of course deliverables and the value associated with each.
It is my expectation that each of you will substantially contribute to the course discussion forums and respond to the posts of at least three other learners.
A substantive post should be at least 200 words. Responses such as “great posts” or “I agree” do notmeet the active engagement expectation.
Please feel free to draw on personal examples as you develop your responses to the Discussion Questions but you do need to demonstrate your understanding of the materials.
I do expect outside sources as well as class materials to formulate your post.
APA format is not necessary for DQ responses, but I do expect a proper citation for references.
Please use peer-related journals found through the GCU library and/or class materials to formulate your answers. Do not try to “Google” DQ’s as I am looking for class materials and examples from the weekly materials.
I will not accept responses that are from Wikipedia, Business com, or other popular business websites. You will not receive credit for generic web searches – this does not demonstrate graduate-level research.
Stay away from the use of personal pronouns when writing.As a graduate student, you are expected to write based on research and gathering of facts. Demonstrating your understanding of the materials is what you will be graded on. You will be marked down for lack of evidence to support your ideas.

Plagiarism

Plagiarism is the act of claiming credit for another’s work, accomplishments, or ideas without appropriate acknowledgment of the source of the information by including in-text citations and references.
This course requires the utilization of APA format for all course deliverables as noted in the course syllabus.
Whether this happens deliberately or inadvertently, whenever plagiarism has occurred, you have committed a Code of Conduct violation.
Please review your LopesWrite report prior to final submission.
Every act of plagiarism, no matter the severity, must be reported to the GCU administration (this includes your DQ’s, posts to your peers, and your papers).

Plagiarism includes:

Representing the ideas, expressions, or materials of another without due credit.
Paraphrasing or condensing ideas from another person’s work without proper citation and referencing.
Failing to document direct quotations without proper citation and referencing.
Depending upon the amount, severity, and frequency of the plagiarism that is committed, students may receive in-class penalties that range from coaching (for a minor omission), -20% grade penalties for resubmission, or zero credit for a specific assignment. University-level penalties may also occur, including suspension or even expulsion from the University.
If you are at all uncertain about what constitutes plagiarism, you should review the resources available in the Student Success Center. Also, please review the University’s policies about plagiarism which are covered in more detail in the GCU Catalog and the Student Handbook.
We will be utilizing the GCU APA Style Guide 7th edition located in the Student Success Center > The Writing Center for all course deliverables.

LopesWrite

All course assignments must be uploaded to the specific Module Assignment Drop Box, and also submitted to LopesWrite every week.
Please ensure that your assignment is uploaded to both locations under the Assignments DropBox. Detailed instructions for using LopesWrite are located in the Student Success Center.

Assignment Submissions

Please note that Microsoft Office is the software requirement at GCU.
I can open Word files or any file that is saved with a .rtf (Rich Text Format) extension. I am unable to open .wps files.
If you are using a “.wps” word processor, please save your files using the .rtf extension that is available from the drop-down box before uploading your files to the Assignment Drop Box.

Grade of Incomplete

The final grade of Incomplete is granted at the discretion of the instructor; however, students must meet certain specific criteria before this grade accommodation is even possible to consider.
The grade of Incomplete is reserved for times when students experience a serious extenuating circumstance or a crisis during the last week of class which prevents the completion of course requirements before the close of the grading period. Students also must pass the course at the time the request is made.
Please contact me personally if you are having difficulties in meeting course requirements or class deadlines during our time together. In addition, if you are experiencing personal challenges or difficulties, it is best to contact the Academic Counselor so that you can discuss the options that might be available to you, as well as each option’s academic and financial repercussions.

Grade Disputes

If you have any questions about a grade you have earned on an individual assignment or activity, please get in touch with mepersonally for further clarification.
While I have made every attempt to grade you fairly, on occasion a misunderstanding may occur, so please allow me the opportunity to learn your perspective if you believe this has occurred. Together, we should be able to resolve grading issues on individual assignments.
However, after we have discussed individual assignments’ point scores, if you still believe that the final grade you have earned at the end of the course is not commensurate with the quality of work you produced for this class, there is a formal Grade Grievance procedurewhich is outlined in the GCU Catalog and Student Handbook.