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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