Week (4): (NRNP 6645 Psychotherapy with Multiple Modalities)
Dorcas Bolaji
College of Nursing-PMHNP, Walden University
NRNP 6645 Comprehensive Psychiatric Evaluation Note and
Patient Case Presentation
PMHNP NURSING
Dr. Susan
Davis
06/27/2022
, NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation
Template
Subjective:
CC (chief complaint): “My mood is good but I stay in my room most of the
time”
HPI: A 16 year old male present himself for the group psychotherapy three
times weekly due to severe depression. Patient walked into the Out Patient
facility accompanied by his step dad. He appears agitated, sad, kept to
himself, hopeless and fatigue. The patient feels frustrated, isolative, and
depressed with low mood due to the fact that his biological father is not in
his life. “I want my dad to be part of my life but he is not there for me and
that got me frustrated”. His biological father has separated from his mother
since he was 6 years old, and only sees him occasionally when he wanted to,
and when he did visit, there is no encouragement, care and concerns about
his son. The patient stated each time he sees his “real” father, he always
tells him to grow up and be a man. His mother stated that he has told him
many times to stop talking to his biological father due to discouraged words
and lacks of care but the patient wanted his father to be part of his life and
never accept his stepdad. This situation has led to severe depression,
anxiety and suicidal attempts, the patient cut his arms multiple times. In
addition, he reported been bullied at school which has led to his inability to
focus, loss of appetite, low energy level, irritable, guilty and helpless. He
denies neither homicidal nor auditory visual hallucination. His mother also
reported that it is hard for the patient to come to terms with his sexuality,
and that he prefers to be homosexual but was not sure how he would be
accepted by others. Mother stated, “Though it is difficult for me to accept
this revelation but I’m coming to terms with it because he is still my son
regardless”
Past Psychiatric History: severe depression and suicidal attempts
• General Statement:
Alert and oriented to place, person and the environment, his mood is
2
, NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation
Template
depressive, anxious and unable to focus at school. Poor coping skills
triggered by father’s separation, anxiety and insomnia. The patient endorsed
homosexuality and not yet able to come to terms with it. This has led to a
great stress and depression to him.
• Caregivers (if applicable): His mother and step dad are his givers
3
Dorcas Bolaji
College of Nursing-PMHNP, Walden University
NRNP 6645 Comprehensive Psychiatric Evaluation Note and
Patient Case Presentation
PMHNP NURSING
Dr. Susan
Davis
06/27/2022
, NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation
Template
Subjective:
CC (chief complaint): “My mood is good but I stay in my room most of the
time”
HPI: A 16 year old male present himself for the group psychotherapy three
times weekly due to severe depression. Patient walked into the Out Patient
facility accompanied by his step dad. He appears agitated, sad, kept to
himself, hopeless and fatigue. The patient feels frustrated, isolative, and
depressed with low mood due to the fact that his biological father is not in
his life. “I want my dad to be part of my life but he is not there for me and
that got me frustrated”. His biological father has separated from his mother
since he was 6 years old, and only sees him occasionally when he wanted to,
and when he did visit, there is no encouragement, care and concerns about
his son. The patient stated each time he sees his “real” father, he always
tells him to grow up and be a man. His mother stated that he has told him
many times to stop talking to his biological father due to discouraged words
and lacks of care but the patient wanted his father to be part of his life and
never accept his stepdad. This situation has led to severe depression,
anxiety and suicidal attempts, the patient cut his arms multiple times. In
addition, he reported been bullied at school which has led to his inability to
focus, loss of appetite, low energy level, irritable, guilty and helpless. He
denies neither homicidal nor auditory visual hallucination. His mother also
reported that it is hard for the patient to come to terms with his sexuality,
and that he prefers to be homosexual but was not sure how he would be
accepted by others. Mother stated, “Though it is difficult for me to accept
this revelation but I’m coming to terms with it because he is still my son
regardless”
Past Psychiatric History: severe depression and suicidal attempts
• General Statement:
Alert and oriented to place, person and the environment, his mood is
2
, NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation
Template
depressive, anxious and unable to focus at school. Poor coping skills
triggered by father’s separation, anxiety and insomnia. The patient endorsed
homosexuality and not yet able to come to terms with it. This has led to a
great stress and depression to him.
• Caregivers (if applicable): His mother and step dad are his givers
3
