Video to use: https://video-alexanderstreet-com.eu1.proxy.openathens.net/watch/training-title-48
Name: Sarah Higgins
Gender: female
Age: 11 years old
T- 97.4 P- 58 R 14 98/62 Ht 4’5 Wt 65lbs
Background: no history of treatment, developmental milestones met on time, vaccinations up to
date. Sleeps 9-10hrs/night, meals are difficult as she has hard time sitting for meals, she does get
proper nutrition per PCP. she has a younger brother. lives with her parents in Washington,
D.C. No hx of head trauma
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
Subjective:
CC (chief complaint):
HPI:
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:
ROS:
• GENERAL:
• HEENT:
• SKIN:
• CARDIOVASCULAR:
• RESPIRATORY:
• GASTROINTESTINAL:
• GENITOURINARY:
• NEUROLOGICAL:
• MUSCULOSKELETAL:
• HEMATOLOGIC:
• LYMPHATICS:
• ENDOCRINOLOGIC:
Objective:
Physical exam: if applicable
Diagnostic results:
Assessment:
Mental Status Examination:
Differential Diagnoses:
Reflections:
References
