NUR 650
Miss Cookie
NUR640CLCPEwk4-2.docx
Comprehensive Psychiatric Evaluation Template
With Psychotherapy Note
Encounter date: 01/22/2026
Patient Initials: J.D. Gender: Male Age: 52 Race: White Ethnicity: Caucasian
Reason for Seeking Health Care: “I can’t stop seeing the things that happened overseas.”
HPI: J.D. is a 52-year-old Caucasian male veteran seeking a psychiatric evaluation due to ongoing post-traumatic stress symptoms stemming from combat experiences 12 years prior. Symptoms emerged shortly after his deployment and have remained without improvement. The issue involves both psychological and neurological components. These symptoms have persisted continuously for over ten years and encompass intrusive recollections, nightmares, flashbacks, emotional numbness, irritability, and heightened alertness. Factors that worsen these symptoms include crowded spaces, loud sounds, and any reminders of combat. Temporary relief is sought through avoidance behaviors and alcohol consumption. Symptoms manifest daily, with an increase in severity at night due to nightmares. The severity is profound, leading to disrupted sleep, a strained marriage, emotional isolation, and challenges in sustaining employment.
SI/HI: Denies suicidal ideation and homicidal ideation.
Sleep: Poor; averages 4 hours per night due to nightmares.
Appetite: Fair; no significant weight changes reported.
Allergies (Drug/Food/Latex/Environmental/Herbal): No known allergies
Current perception of Health: Fair. J.D. reports that ongoing PTSD symptoms, poor sleep, and emotional distress negatively impact his daily functioning and overall quality of life.
Psychiatric History:
Inpatient hospitalizations: None
Outpatient psychiatric treatment: None prior to this visit.
Detox/Inpatient substance treatment: None
History of suicide attempts and/or self injurious behaviors: Denies
Past Medical History
Major/Chronic Illnesses: Hypertension, diagnosed 2018 – active
Trauma/Injury: Combat-related psychological trauma
Hospitalizations: None reported
Past Surgical History: None reported
Current psychotropic medications: None
Current prescription medications: Lisinopril 10 mg PO daily
Amlodipine 5 mg PO daily
Hydrochlorothiazide 25 mg PO daily
OTC/Nutritionals/Herbal/Complementary therapy: Chamomile tea is a herbal supplement taken nightly for sleep support
Substance use : (alcohol, marijuana, cocaine, caffeine, cigarettes)
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Substance |
Amount |
Frequency |
Length of Use |
|
Alcohol |
2-3 can |
Nightly |
4 years |
|
Marijuana |
Denies |
|
|
|
Caffeine |
1-2 cups |
Daily |
Over 10 years |
|
Cigarettes |
Quit 4 year ago |
|
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Family Psychiatric History:
Mother: Anxiety
Father: Depression
Brother: Alcohol use disorder
Uncle : Anxiety disorder was recently diagnosed
Aunt: Paranoia
Paternal grandfather : Alcohol use disorder
No known family history of bipolar disorder or suicide attempts
Social History
Lives: Single family House/Condo/ with stairs: living in a single family home with spouse over 20 years
Marital Status: Married
Education: High school graduate went straight into the military
Employment Status: Full-time worker Current/Previous occupation type: Warehouse supervisor Exposure to: Smoke: work related ETOH: 2 to 3 beers nightly Recreational Drug Use: Denies
Sexual Orientation: Heterosexual Sexual Activity: Active with spouse Contraception Use: None
Family Composition: Family/Mother/Father/Alone : Lives with spouse and had 4 children together, 3 boys and 1 girl. 15 grandchildren.
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx): Born and raised in Florida, Veteran with multiple overseas deployments; avoids crowds; limited social interactions; strained marriage; no legal issues; enjoys working on cars. Health Maintenance
Screening Tests (submit with SOAP note):
PTSD Checklist for DSM-5 (PCL-5): Score 60, exceeding the clinical cutoff and indicating severe PTSD symptoms, including intrusive memories, nightmares, avoidance, and hyperarousal, consistent with chronic PTSD.
Patient Health Questionnaire-9 (PHQ-9): Score 12, indicating moderate depressive symptoms, likely secondary to chronic trauma-related distress.
Generalized Anxiety Disorder-7 (GAD-7): Score 7, indicating mild anxiety symptoms, primarily associated with hyperarousal and trauma-related triggers.
Immunization HX: Influenza vaccine overdue.
Review of Systems (at least 3 areas per system):
General: Admits fatigue; denies fever or weight loss. HEENT: Denies headaches, dizziness or vision problems
Neck: Denies pain , stiffness or inflammation
Lungs: Denies shortness of breath, cough or wheezing
Cardiovascular: Admit chest pain and palpitations during nightmare
Breast: Denies masses, pain or dischage
GI: denies abdominal pain, nausea and vomiting
Male/female genital: Denies pain, smell or discharge
GU: Denies urinary symptoms
Neuro: Admits hyperarousal, seizures or confusions
Musculoskeletal: Admits muscle tension; Denies joint pain
Activity & Exercise: Limited physical activity
Psychosocial: Admits anxiety, irritability, emotional detachment. Derm: Denies rashes, bruises or bumps
Nutrition: Fair appetite
Sleep/Rest: Difficulty maintaining sleep
LMP: N/A
STI Hx: Denies
Physical Exam
BP: 128/82 mmHg (sitting) TPR: 98.3°F oral HR: 88 bpm RR: 18 breaths/min Ht: 5’11” Wt: 225 lbs BMI: 31.4 Pain Level: 0/10
Mental Status Exam
Appearance: Well-groomed, casually dressed, appears stated age.
Behavior: Guarded but cooperative and engaged with appropriate eye contact.
Speech: Normal rate, rhythm, and volume; coherent and fluent.
Mood: “Irritable.”
Affect: Anxious and congruent with mood; appropriate to content.
Thought Content: Trauma-focused with intrusive memories; no delusions or suicidal/homicidal ideation.
Thought Process: Denies auditory or visual hallucinations, illusions, or dissociative perceptual disturbances.
Perception: Denies hallucinations or perceptual disturbances.
Cognition/Intelligence: Alert and oriented ×4; memory and concentration intact.
Clinical Insight: Fair; recognizes impact of trauma-related symptoms on functioning..
Clinical Judgment: Fair; able to participate in treatment but continues avoidance behaviors.
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Psychotherapy Note |
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Therapeutic Technique Used: Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) with elements of prolonged exposure. |
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Session Focus and Theme: This session focused on processing trauma related symptoms, including intrusive memories, nightmares, hypervigilance, and avoidance behaviors. We emphasized understanding how trauma continues to affect mood, sleep, and interpersonal functioning. |
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Intervention Strategies Implemented: · Provided psychoeducation on PTSD and the trauma response. · Explored trauma-related triggers. · Initiated cognitive restructuring to challenge maladaptive beliefs related to trauma. · Introduced grounding techniques to help manage hyperarousal. · Discussed gradual exposure strategies to reduce avoidance behaviors. |
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Evidence of Patient Response: J.D. was engaged and cooperative throughout the session, demonstrated increased insight into how trauma related triggers contribute to symptoms, actively participated in grounding exercises, and verbalized willingness to practice coping strategies and continue trauma focused psychotherapy. |
Plan:
Differential Diagnoses
F32.1- Major Depressive Disorder, moderate: Considered due to low mood, fatigue, sleep disturbance, and emotional withdrawal; however, symptoms appear secondary to trauma-related distress rather than a primary mood disorder (APA, 2023).
2. F41.1- Generalized Anxiety Disorder : Considered because of excessive worry, irritability, and muscle tension, though anxiety is largely trauma triggered and situational rather than generalized (APA, 2023).
Principal Diagnoses
F43.12- Post-Traumatic Stress Disorder, Chronic: Confirmed based on combat trauma exposure, persistent intrusive memories and nightmares, avoidance behaviors, hyperarousal, functional impairment, and a PCL-5 score indicating severe PTSD.
Plan:
Diagnosis #1 PTSD, Chronic
Diagnostic Testing/Screening: Monitor PTSD symptoms using the PCL-5 at follow-up visits to assess treatment response. No laboratory testing is clinically indicated at this time due to absence of medical instability or medication related concerns.
Pharmacological Treatment: Initiate Sertraline 50 mg PO daily first-line pharmacologic treatment for PTSD
Non-Pharmacological Treatment: Initiate trauma-focused cognitive behavioral therapy (TF-CBT) with prolonged exposure therapy weekly to address intrusive symptoms, avoidance behaviors, negative trauma-related beliefs, and hyperarousal in PTSD (APA, 2023; Watts et al., 2020).
Patient/Family Education: Provided education on PTSD symptoms, treatment expectations, coping strategies, sleep hygiene, and the importance of medication and therapy adherence (VA/DoD, 2023).
Referrals: VA trauma therapy program and veterans peer support group for specialized care and social support (VA/DoD, 2023) .
Follow-up: Return in 4 weeks for reassessment of symptoms, medication tolerance, and treatment engagement.
Anticipatory Guidance: Advised patient to monitor for worsening mood, sleep disturbance, increased anxiety, or suicidal ideation and to seek immediate care if symptoms escalate.
Safety Planning
• Crisis Hotline: 988
• ER instructions for suicidal thoughts with plan or intent
• Involve family in support and monitoring
• Written safety contract reviewed and signed
Signature (with appropriate credentials): Andcherla Marcelin, MSN, ARNP, PMHNP-BC
DDEA#: AM6843088 STU Clinic LIC# APRN11003548
Tel: (305) 814-3442 FAX: (305) 814-3440
Patient Name: (Initials) J.D. Age 52
Date: 1/22/2026
RX Sertraline 50 mg tablets
SIG: Take one tablet by month once a day
Dispense: 30 Refill: 0
No Substitution
Signature: Andcherla Marcelin, MSN, ARNP, PMHNP-BC
References
American Psychiatric Association. (2023). Practice guideline for the treatment of patients with posttraumatic stress disorder. American Psychiatric Publishing.
Department of Veterans Affairs & Department of Defense. (2023). VA/DoD clinical practice guideline for the management of posttraumatic stress disorder and acute stress disorder. https://www.healthquality.va.gov
Lewis, C., Roberts, N. P., Gibson, S., & Dropinski, J. (2020). Dropout rates from psychological therapies for post-traumatic stress disorder (PTSD) in adults: A meta-analysis. Journal of Anxiety Disorders, 75, 102293. https://doi.org/10.1016/j.janxdis.2020.102293
Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2023). The PTSD Checklist for DSM-5 (PCL-5): Development and psychometric evaluation. Journal of Traumatic Stress, 36(1), 1–14.
Watts, B. V., Schnurr, P. P., Mayo, L., Young-Xu, Y., Weeks, W. B., & Friedman, M. J. (2020). Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. Journal of Clinical Psychiatry, 81(3), 19r13011. https://doi.org/10.4088/JCP.19r13011
Rev. 2272022 LM
