Neurodevelopmental Disorder

Training Title 38 Name: Mr. Elijah Loman Gender: male Age:18 years old T- 98.3 P- 93 R 22 118/68 Ht 5’7 Wt 149lbs Background: Currently lives with his sister and two parents in Durham, NC. Not currently employed. Completed high school, not currently in school. Hx of treatment for mood disorder began age 15, previous trials of risperidone, quetiapine off and on, side effects of wt. gain. Has hx of a six-day hospitalization one year ago after found wandering at night in the mall parking lot without clothes. He refused medication due to previous experiences. Not currently partnered. He has been sexually inappropriate with comments to female neighbors; pulled his pants down in the mall. Denies any recent alcohol or substance use. Father has history of bipolar disorder. No history of self-harm behaviors, no family suicides. Mother reports he has slept 4-5 hours in past week, up spending money buying and playing new video games and says he is writing a book on how others can be a video game master. Appetite is decreased. No medical hx; Hx of vandalism as a juvenile. Has pending court date for indecent exposure. Allergies: latex

Symptom Media. (Producer). (2016). Training title 38 [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa tch/training-title-38

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint):

HPI:

Past Psychiatric History:

· General Statement:

· Caregivers (if applicable):

· Hospitalizations:

· Medication trials:

· Psychotherapy or Previous Psychiatric Diagnosis:

Substance Current Use and History:

Family Psychiatric/Substance Use History:

Psychosocial History:

Medical History:

· Current Medications:

· Allergies:

· Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Physical exam: if applicable

Diagnostic results:

Assessment:

Mental Status Examination:

Differential Diagnoses:

Reflections:

References

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