Comprehensive psychiatric evaluations are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
Chief compliant (CC). His chief complaint is, “depress and anxiety due to divorce”.
HISTORY: Patient is a 44 years old Caucasian male patient with history of hyperlipemia, Alcohol use disorder,
cannabis use, tobacco use, generalized anxiety disorder, Major depressive disorder that is
managed on lamotrigine, hydroxyzine, Propanolol in the past. He is on Lexopro 10mg daily and
Clonazepam 0.5mg BID. He does CBT with Mid Atlantic therapist. He endorsed tolerability and
adherence.
Symptoms/Behavior Patient reported that his divorced was finalized in 2019 to his wife of 14 years. Patient endorsed
working as engineer at Verizon and has another degree in psychology. Patient endorse improved
low energy, lack of motivation, anhedonia, poor appetite, poor sleep, irritability, anxiety, isolative,
but denies hopelessness, hopelessness, and guilty feelings. Patient endorsed improved nervous,
uncontrol worries, irritability, worrying about different things, anxious and fear of impending doom.
Patient endorsed improved racing thoughts, mood swings, irritable, impulsivity, spending spree,
grandiosity, and risky behaviors. Patient denies mania, hypomania, PTSD and psychosis. Patient
denies history of abuse or trauma. Patent reported sleeps 8 hours nightly without of nightmares.
Patient with history AUD, reported his last alcohol use to be November 2020. Patient smoked
1PPD cigarette smoker for 30 years endorsed vaping now. He last Cannabis use was yesterday
August 13, 2021. He denies other recreational drugs. He denies audio / visual hallucination. Patient
denies death wish, he vehemently suicidal and homicidal ideation, intent or plain and verbally
contracted safety. Patient reported atheist faith, his friends, and family, his dog (Amber) as his
protective factor.
7/17/1977DOB:
PAST PSYCHIATRIC HISTORY:
Addiction/Use History: Alcohol use disorder,
Tobacco use,
Psychotropic Medication History:
lamotrigine, hydroxyzine, Propanolol in the past.
He is on Lexapro 10mg daily and Clonazepam 0.5mg BID.
Outpatient Treatment:
He does CBT with Mid Atlantic therapist.
SOCIAL/DEVELOPMENTAL HISTORY:
Mr. Rice is a divorced 44 year old man. He is Not Hispanic or Latino. He is a Atheist. His
emergency contact is his Elizabeth Rice
Development History:
Details of Mr. Rice’s developmental history are not available at this time.
FAMILY HISTORY:
Father has depression, Brain tumor and TBI.
Mother had GAD.
Sister was Depression and anxiety
MEDICAL HISTORY:
hyperlipemia
EXAM: Mr. Rice appears sad looking, He exhibits speech that is normal in rate, volume, and
articulation and is coherent and spontaneous. Language skills are intact. Signs of moderate
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):
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
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