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 them altogether as one document.

sychiatric 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 them 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 (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 Order this paper