Psychotherapy

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

Students Name.

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Faculty Name

October 2021

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

CC (chief complaint): “Slipped back into depression”

HPI: Pt is a 56 year old female who came for her psychiatrist vsit complaining that she has been slipping back into depression lately. That all she does is sleep all day and she dose not feel like doing any thing or even helping her husband with anything. She is tried of that and wants to see if she can get a kind of routine for herself and be helpful to herself and her husband. Pt also complained of having some hallucination sometimes . Her weight is a part of her problem. It gets her depressed.

Past Psychiatric History:

· General Statement: Pt has ben seeing a psychiatrist as a teenager for her Bipoar disorder.

· Caregivers (if applicable):Pt lives with the husband who is caring.

· Hospitalizations: There are no recent hospitalizations noted.

· Medication trials: Pt is not on any medication trial at this time.

· Psychotherapy or Previous Psychiatric Diagnosis: Bipolar Disorder / Eating Disorder / Depression and Attention Deficit Disorder.

Substance Current Use and History: Pt is not using any substance.

Family Psychiatric/Substance Use History: No family history of psychiatric or substance use disorder.

Psychosocial History: Pt is a stay home mum who was born and raised in US. Pt is presently living with her husband. Her kids ae grown and stays by themselves. Pt is educated but is not working now. She stays home now. There is no record of any childhood or adult trauma noted. Pt feels safe at home.

Medical History:

· Current Medications: Trileptor 30 mg, Lamatrogine 40mg, Latude 60 mg, Viibryd

· Allergies: NKDA

· Reproductive Hx: Pt has 3 children who are all grown.

ROS:

· GENERAL: Pt is

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Physical exam: if applicable

Diagnostic results:

Assessment

Mental Status Examination:

Differential Diagnoses:

Reflections:

References