Rhonda Renee Henry
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan
II Dr. Paula Robinson
December 8th, 2025
WALDEN UNIVERSITY, LLC
, Pathways Mental Health
PSYCHIATRIC PATIENT EVALUATION
INSTRUCTIONS Use the following case template to complete Week 2 Assignment 1. Assign DSM-5-TR
diagnoses and ICD-10 codes to the services documented in the case scenario. You will add
your narrative answers to the assignment questions at the bottom of this template and
submit them together as one document.
IDENTIFYING Identification was verified by stating their name and date of birth.
INFORMATION
Time spent for evaluation: 1103am-1151am
CHIEF COMPLAINT “My primary doctor thinks I need more help than she can give me now.”
HPI
42 42-year-old female was evaluated for psychiatric evaluation and referred by her primary care
provider for worsening depression and panic symptoms. She is currently prescribed
escitalopram 5mg PO daily for depression and alprazolam 1mg PO daily for anxiety. Today, the
client reported symptoms of worsening in the past month for depression with anergia,
anhedonia, motivation, reports anxiety, frequent worry, reports feeling restlessness,
palpitations, “feels like everything is closing in on me, cannot focus, hard time breathing,” no
reported obsessive/compulsive behaviors. The client reported feelings like wanting to sleep and
never waking up. 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 is
easily frustrated. Has low frustration tolerance, sleeps 10-12 hrs/24 hours, and has a decreased
appetite. 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 week: Severity Measure for Panic Disorder = Total Score 38
PAST PSYCHIATRIC • Entered the mental health system when she was 29 after a family suicide.
AND SUBSTANCE • Previous Psychiatric Hospitalizations:
• Previous Detox/Residential treatments:
Page | 1 Walden University, LLC rev 4.2024
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan
II Dr. Paula Robinson
December 8th, 2025
WALDEN UNIVERSITY, LLC
, Pathways Mental Health
PSYCHIATRIC PATIENT EVALUATION
INSTRUCTIONS Use the following case template to complete Week 2 Assignment 1. Assign DSM-5-TR
diagnoses and ICD-10 codes to the services documented in the case scenario. You will add
your narrative answers to the assignment questions at the bottom of this template and
submit them together as one document.
IDENTIFYING Identification was verified by stating their name and date of birth.
INFORMATION
Time spent for evaluation: 1103am-1151am
CHIEF COMPLAINT “My primary doctor thinks I need more help than she can give me now.”
HPI
42 42-year-old female was evaluated for psychiatric evaluation and referred by her primary care
provider for worsening depression and panic symptoms. She is currently prescribed
escitalopram 5mg PO daily for depression and alprazolam 1mg PO daily for anxiety. Today, the
client reported symptoms of worsening in the past month for depression with anergia,
anhedonia, motivation, reports anxiety, frequent worry, reports feeling restlessness,
palpitations, “feels like everything is closing in on me, cannot focus, hard time breathing,” no
reported obsessive/compulsive behaviors. The client reported feelings like wanting to sleep and
never waking up. 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 is
easily frustrated. Has low frustration tolerance, sleeps 10-12 hrs/24 hours, and has a decreased
appetite. 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 week: Severity Measure for Panic Disorder = Total Score 38
PAST PSYCHIATRIC • Entered the mental health system when she was 29 after a family suicide.
AND SUBSTANCE • Previous Psychiatric Hospitalizations:
• Previous Detox/Residential treatments:
Page | 1 Walden University, LLC rev 4.2024
