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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Assignment Instructions:

Answer with minumun 2 paragraphs each the following questions based in the bellow clinical case:

1. What other additional differential diagnosis is applicable based on the presention symptoms? explain

2. What additional history is required to confirm the diagnosis?

3. What other medications would be applicable in her situation?

** At least 2 references per question**


CC (chief complaint): “I need help, I feel empty and overwhelmed by sadness”.

HPI: Client MM is a 33-year-old Caucasian female who was referred from the women center after she lost a term pregnancy of twins 13 months ago. She presented for a psychiatric evaluation with her husband in attendance. They both looked very sad. She reported that the reason for referral was because she was very depressed after losing her pregnancy and was having suicidal thoughts. She was started on Zoloft 50 mg pod once a day at the women center. She currently denies any suicidal or homicidal ideation. She is feeling intense sadness. Admits to having rumination thoughts. She is still grieving the loss of her pregnancy. Admits that she has not been able to get back to work after the burying her babies remain. She said she has lost interest in doing things she enjoys doing. Admits to have lost her appetite and is skipping meals. She has poor memory and concentration. Denies any distractibility. She has poor sleep, sleeps 4 to 5 hours per night. Patient endorse hopelessness, helplessness and worthlessness, however, she said she is not suicidal at this time. Reports to be anxious. Admits to racing thoughts and mood swing. Admits to nightmares. Denies paranoia, delusions and hallucination. PHQ-9 score 24.

Past psychiatric history: Denies any previous psychiatric history.

Social history: She was born and brought up in New York, they moved to Florida when she was young and went to school in Florida. She is a college graduate. Reports that her childhood was good and had very supportive parents and extended family. She is the first born in a family of four two sisters and one brother. The rest of her sibling lives with their parents. The two sisters work at the post office and the brother who is the youngest is in the navy. She is married and lives with her husband, they have no children together. She reports to have had two previous miscarriages. Reports that they are experiencing marital issues but she does not want to discuss more on that. She works as a technician in a phone company. Her husband is a teacher. Her parents are alive and well.

Family history of Psychiatric illness: Denies any psychiatric illness in her family.

Substance Cur