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
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
© 2021 Walden University Page 1 of 3
**Week #: 1**
**Comprehensive Psychiatric Evaluation: Initial Assessment**
**Student Name**
**College of Nursing-PMHNP, Walden University**
**NRNP 6635: Psychopathology and Diagnostic Reasoning**
**Faculty Name**
**Assignment Due Date**
**Subjective:**
**Chief Complaint (CC):**
The patient presents with symptoms of persistent sadness, loss of interest in activities, decreased energy, and feelings of worthlessness.
**History of Present Illness (HPI):**
The patient reports experiencing depressive symptoms for the past six months. Symptoms include feelings of hopelessness, difficulty concentrating, and impaired sleep and appetite. The patient denies any suicidal ideation but admits to occasional thoughts of self-harm.
**Past Psychiatric History:**
– General Statement: No previous psychiatric diagnoses or treatment.
– Caregivers (if applicable): None reported.
– Hospitalizations: No psychiatric hospitalizations.
– Medication Trials: No previous trials of psychiatric medications.
– Psychotherapy or Previous Psychiatric Diagnosis: No previous psychotherapy or psychiatric diagnoses.
**Substance Current Use and History:**
The patient denies current substance use. There is no history of substance abuse or dependence.
**Family Psychiatric/Substance Use History:**
There is a family history of depression in the patient’s maternal grandmother and aunt.
**Psychosocial History:**
The patient is currently unemployed and lives alone. She reports a history of interpersonal conflicts with family members.
**Medical History:**
– Current Medications: None reported.
– Allergies: No known drug allergies.
– Reproductive Hx: The patient reports a history of irregular menstrual cycles.
**Review of Systems (ROS):**
– GENERAL: No fevers, chills, or weight changes.
– HEENT: No visual or auditory changes.
– SKIN: No rashes or lesions.
– CARDIOVASCULAR: No chest pain or palpitations.
– RESPIRATORY: No cough or shortness of breath.
– GASTROINTESTINAL: No nausea, vomiting, or diarrhea.
– GENITOURINARY: No urinary symptoms.
– NEUROLOGICAL: No headaches or seizures.
– MUSCULOSKELETAL: No joint pain or stiffness.
– HEMATOLOGIC: No history of bleeding disorders.
– LYMPHATICS: No swollen glands.
– ENDOCRINOLOGIC: No heat or cold intolerance.
**Objective:**
**Physical Exam:**
Vital signs: BP 120/80 mmHg, HR 72 bpm, RR 16/min, Temp 98.6°F.
General: Alert and oriented x3, cooperative.
Mental Status Examination: Depressed mood, flat affect, psychomotor retardation.
**Diagnostic Results:**
No diagnostic results available at this time.
**Assessment:**
**Mental Status Examination:**
Ms. A presents with a depressed mood, flat affect, and psychomotor retardation. She reports feelings of worthlessness and difficulty concentrating. No evidence of psychotic symptoms.
**Differential Diagnoses:**
- Major Depressive Disorder (MDD)
- Persistent Depressive Disorder (PDD)
- Adjustment Disorder with Depressed Mood
**Reflections:**
The patient’s presentation is consistent with a depressive disorder, likely Major Depressive Disorder given the severity and duration of symptoms. Further assessment and diagnostic evaluation are warranted to confirm the diagnosis and develop an appropriate treatment plan.
**References:**
*References would be included here, formatted in current APA style.*
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