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
, NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
Subjective:
CC (chief complaint): Jess's two roommates are concerned about her behaviors
and bring her for evaluation.
HPI: Ms Jess Davis is a 30-year-old female with significant behavioral changes.
She was presented by roommates for mental assessment after observing
significant changes in sleeping and eating habits. The death of her aunt triggered
depression; however, this condition worsened after witnessing the death of her
brother. This traumatic event took place during a burglary at a gas station, where
her brother was shot and died from the wound. This situation has, therefore,
contributed to the severe sleep disorder. The roommates observed that she only
sleeps for two hours, and her diet involves canned food. Further, she started
smoking cannabis at seventeen years a habit that has developed into daily
consumption. It is also noted that she enjoys a few beers with friends on
weekdays. To reduce symptoms of anxiety, her physician prescribed him 1 mg of
Alprazolam to take twice every day for fifteen days. She reported working in a
bakery and did not have a close relationship with her parents.
Past Psychiatric History:
General Statement: Jess became depressed after the death of her aunt.
Caregivers (if applicable): She has no caregiver
Hospitalizations: Not reported.
Medication trials: 1 mg Alprazolam taken twice
Psychotherapy or Previous Psychiatric Diagnosis: No history of psychotherapy
Substance Current Use and History: Jess has been a cannabis user for the past 13
years. She also consumes alcohol during weekdays with her roommate.
Family Psychiatric/Substance Use History: No report of family background.
Psychosocial History: Her brother was the only sibling and had an emotional
relationship with their parents. She shares accommodation with roommates with whom
she spends time, including weekday outings. While no educational information was
reported, she works at a bakery.
Medical History: No chronic diseases or surgical procedures were reported.
Current Medications: 1 mg Alprazolam
Allergies: Medical tape
Reproductive Hx: Not reported
ROS:
© 2021 Walden University Page 2 of 5
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
, NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
Subjective:
CC (chief complaint): Jess's two roommates are concerned about her behaviors
and bring her for evaluation.
HPI: Ms Jess Davis is a 30-year-old female with significant behavioral changes.
She was presented by roommates for mental assessment after observing
significant changes in sleeping and eating habits. The death of her aunt triggered
depression; however, this condition worsened after witnessing the death of her
brother. This traumatic event took place during a burglary at a gas station, where
her brother was shot and died from the wound. This situation has, therefore,
contributed to the severe sleep disorder. The roommates observed that she only
sleeps for two hours, and her diet involves canned food. Further, she started
smoking cannabis at seventeen years a habit that has developed into daily
consumption. It is also noted that she enjoys a few beers with friends on
weekdays. To reduce symptoms of anxiety, her physician prescribed him 1 mg of
Alprazolam to take twice every day for fifteen days. She reported working in a
bakery and did not have a close relationship with her parents.
Past Psychiatric History:
General Statement: Jess became depressed after the death of her aunt.
Caregivers (if applicable): She has no caregiver
Hospitalizations: Not reported.
Medication trials: 1 mg Alprazolam taken twice
Psychotherapy or Previous Psychiatric Diagnosis: No history of psychotherapy
Substance Current Use and History: Jess has been a cannabis user for the past 13
years. She also consumes alcohol during weekdays with her roommate.
Family Psychiatric/Substance Use History: No report of family background.
Psychosocial History: Her brother was the only sibling and had an emotional
relationship with their parents. She shares accommodation with roommates with whom
she spends time, including weekday outings. While no educational information was
reported, she works at a bakery.
Medical History: No chronic diseases or surgical procedures were reported.
Current Medications: 1 mg Alprazolam
Allergies: Medical tape
Reproductive Hx: Not reported
ROS:
© 2021 Walden University Page 2 of 5
