Assignment: Assessing and Diagnosing Patients with Neurocognitive and Neurodevelopmental Disorders

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

Appearance: 25-year-old African American female, appears stated age, wearing paper hospital scrubs that have been cut to reveal abdomen with vertical abdominal scar visible, and multiple tattoos of various names visible on forearms bilaterally.

Behavior: Not in acute distress, difficult to redirect for interviewing, inappropriately laughing and smiling

Motor Activity: Minimal psychomotor agitation present. Regular gait. Regular posturing. No tics, tremors, or EPS present.

Speech: Hyperverbal, fluent, pressured rate, regular rhythm, regular volume, happy tone

Mood: “Fantastic”

Affect: Elated, inappropriate, congruent

Thought Process: Flight of ideas

Thought Content: Denies suicidal ideations, denies homicidal ideations. Grandiose delusions elicited of being “an angel on a mission.”

Perceptions: Endorses auditory hallucinations of God commanding her to go to California. Denies visual hallucinations. Does not appear to be actively responding to internal stimuli.

Cognition: 

Sensorium/orientation: Alert and oriented to person, place, and date 

Attention/concentration: Poor. Unable to spell WORLD forward and backward.

Memory: Able to recall 3/3 objects immediately and after 1 minute. Recent memory - Intact to breakfast this morning. Long-term memory - Intact to what high school she attended.

Abstract reasoning: Intact with the ability to identify a bird and tree as both living.

Insight: Poor

Judgment: Poor

Name: Ms. Jess Cunningham Gender: female Age: 28 years old T- 98.6 P- 86 R 20 120/70 Ht 5’2 Wt 126lbs Background: Jess is brought for evaluation by her 2 roommates who are concerned with behaviors that began 12 days after Jess’s younger brother committed suicide in front of her via GSW after his girlfriend broke up with him. She is estranged from her parents and her brother was her only sibling. She is only sleeping 1–2 hours/24hrs; she will only canned foods. She smokes cannabis daily since she was 16, goes out on weekdays 2–3 times with her roommates and has couple drinks of beer. She was prescribed alprazolam 1mg twice daily as needed by her PCP for 15 days. She works as a bartender. Symptom Media. (Producer). (2016). Training title 24 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-24