Assignment: Assessing and Diagnosing Patients With Mood Disorders

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): I am not doing well this time of the year

HPI: HPI: J. H. is a 19-year-old white female who presents for psychiatric evaluation. She complained

of not doing well in school, but she verbalized that she felt okay. She is in a particular business

program, but she cannot seem to get it done where she is already late on passing two projects.

She left the program at school. She stated that after reading the newspaper, she could not

remember what she just read. She stated that the teacher is getting to be a bit of a pain. She also

reports being unable to concentrate, and she slept through five of her classes this month. She said

that she could make friends and later they got dull. She reports that she lost interest quickly and

gets mood swings a little bit, and she cannot get over anything. With the weather this time of the

year, she stated that it is dark, gray, and miserable—the whole city changes. The patient does not

like winter. The patient is not currently on any prescribed psychotropic medication.

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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