Assignment 2: Comprehensive Psychiatric Evaluation Note And Patient Case Presentation essay paper

Assignment 2: Comprehensive Psychiatric Evaluation Note And Patient Case Presentation

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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:

(include psychiatric ROS rule out)

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:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Differential Diagnoses:

Reflections:

Case Formulation and Treatment Plan:

References

 CASE STUDY

HPI..The pt is an O.L. is an 17-year-old Caucasian female. The evaluation is a routine appointment for this patient, she is seen weekly. She is seen for depression and anxiety. She is currently prescribed Celexa 20 mg q am and Vistaril 25 mg as needed. The patient reports feeling down, over tired, sleeping too much, and overwhelming anxiety. The patient reportsAssignment 2: Comprehensive Psychiatric Evaluation Note And Patient Case Presentation

Chief complaint. “I feel like im sleeping way too much, and if I’m saying that, I probably am sleeping too much”per pt. The patient reports that this makes her feel cranky. She says that she becomes easily irritated and angry with her mother and boyfriend. The patient reports feeling these symptoms for the last 2 months and have intensified in the last one month. The patient reported an incident where she was attending a family reunion and felt very anxious when she learned that 55 plus members were attending. The patient reported feeling uncomfortable and feeling like she could not catch her breath. The patient reports feeling like she could not get enough air. The patient reports feeling these symptoms at random times. The patient also reports feelings of energy at times followed by a good mood and then feeling very tired and irritable for a few days.Assignment 2: Comprehensive Psychiatric Evaluation Note And Patient Case Presentation

The patient began psychotherapy treatment at the age of 17 and medication management with a separate provider. The patient reports being hospitalized last month after consuming a large amount of alcohol while on vacation with her family. She has never been hospitalized before this incident. The patient has been receiving psychotherapy for since October 2021. The patient reports “my mom said that my dad was a stoner” per pt. The patient reports that her father no longer smokes marijuana and her mother drinks alcohol 2-3 times a week. There is no history of suicide or mental on the paternal and maternal sides of the family. Psychosocial History: The patient was born and raised in phoenix Arizona She has a younger biological sister (15). The patient currently lives with her Mother, Step-Father, and biological sister. The patient’s parents divorced when she was 9 yrs old. The patient has a strained relationship with her father. The two argue mostly every time they communicate. The patient also reports arguing with her sister frequently and her mother. The patient reports. The patient is currently in the 11th grade. The patient works as a nanny for family friend. The patient enjoys spending time with her friends. The patient reports being hospitalized last month after consuming a large amount of alcohol while on vacation with her family. The patient reports that she drinks alcohol  a week and blacks out on occasion. The patient smokes marijuana several times a day. She reports that she is able to get her school work completed if she smokes marijuana beforehand. The patient does not have any current legal issues and has not had any past legal issues. The patient reports trauma as a child while spending time with her father. The patient reports that her father is a Sheriff and that during off duty hours the father would keep his police radio on, the father would respond to calls while off duty when he had the patient and her sister with him. The patient was exposed to domestic cases and drug over doses. The patient explains that these events were traumatic for her. There is no history or physical or sexual violence according to the patient.Assignment 2: Comprehensive Psychiatric Evaluation Note And Patient Case Presentation