Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6645: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint):
HPI:
(include psychiatric ROS rule out)
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:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Differential Diagnoses:
Reflections:
Case Formulation and Treatment Plan:
References
Pt Name: A.C
Age: 13 Years old.
Diagnosis: ADHD / Major Depressive Disorder / Generalized Anxiety Disorder
Chief Complain: Arrested by Police.
Student Note: Pt is a 13-year-old female, who presented to the clinic with the grand mum stating that she was hospitalized at the hospital twice because of behavioral issues. Pt pulled a knife on the sister during an argument and was arrested and sent to the hospital. Back in May, she was arrested by the police because of arguing with a police officer. Pt was asked if she was on her medications before she pulled the knife on the sister and she said yes. Pt said she do argue with teachers at school for different reasons. Pt was released from the hospital last two weeks and she argued with the family members over leaving a toy gun in her house. She said there has not been much improvement with her medications. Pt has not been consistent with her medication. Pt has anger problem, increased energy, depression, fearful, guilt, helplessness, hopelessness, loss of interest in things, feels she is better off dead, using drugs like weeds, marijuana, Nicotine. Pt used to be in school volleyball but was suspended because of behavioral issues. Pt was asked what kind of help she needs but she does not know. Her medications were reviewed, and some changes were made but pt is educated on the importance of taking her medications. Her medications include Latuda 40 mg once daily with food, Lexapro 5 mg x 3 daily, Buspirone 15 mg x 3 daily, Lorazepam 20 mg once daily. Pt’s medication was sent to the pharmacy, and she is to follow up in two weeks.
