Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Training Title 28 Name: Mrs. Ada Carson Gender: female Age: 54 years old T- 97.6 P- 94 R 22 162/84 Ht 5’5 Wt 144lbs Background: Currently living in Sioux Falls, South Dakota, working full-time as a contract negotiator in a financial company. Has an MBA. Lives with her husband and two teenage twin sons. Born and raised in Trenton, NJ, with her father and two brothers, her mother deceased when she in MVA when she was 12 years old. Brother has depression; mother has history of being a “functioning alcoholic”. Recently informed by her PCP she has a “fatty liver.” Allergies: codeine Symptom Media. (Producer). (2016). Training title 28 [Video].

https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa tch/training-title-28

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

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

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