Week 3: Mood Disorders
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): “I'm terrible. Alright. I look terrible, I feel terrible. My body is bloated. I
have lines on my face, bags. I look disgusting.”
HPI: The patient, a 32-year-old female and a stay-at-home mother presents to the clinic for
psychiatric evaluation for mood disorders. She states that since she gave birth two months ago,
she hardly sleeps since the baby (Jessica) keeps crying all the time. The patient indicates that she
doesn’t recognize her baby and constantly blames herself for all that is happening. She yells a lot
and everything that her husband does upsets her. Leslie indicates that she has gained weight
after giving birth, an aspect that makes her feel terrible since she feels that she looks disgusting.
As a result, she has planned to exercise by running but since is always taking care of the baby,
she hardly gets out. Together with her husband Rick, the couple cannot afford a baby-sitter. The
patient states that the relationship with her husband is not good and wants to leave her marriage
but does not want to ruin the “perfect family” as Rick always come home from work and plays
with Jessica. Leslie has no social life since she no friends. She has also lost interest in activities
that once looked forward to, such as writing. Due to constant feelings of sadness, Leslie has
contemplated suicide but she is unable to kills herself. As a result, she feels stuck between a rock
and hard place, a situation that makes her sadder. Currently, she is not on any psychotropic
medication.
Past Psychiatric History:
General Statement:
Caregivers (if applicable):
Hospitalizations:
Medication trials:
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NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
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:
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NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
Objective:
Physical exam: if applicable
Diagnostic results:
Assessment:
Mental Status Examination:
Differential Diagnoses:
Reflections:
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NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
References
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