clinical
Chief Complaint: The patient presents for evaluation and management of substance abuse. History of Present Illness: The patient is a 20-year-old male who reports using marijuana over the past [du1 1 year. The patient describes escalating use, resulting in negative impacts on his academic performance, relationships, and physical health. He reports using the substance to cope with stress and to achieve a sense of euphoria. The patient acknowledges a loss of control over his use and has attempted to cut down without success.
Week (enter week #): (Enter assignment title)
Student Name
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College of Nursing-PMHNP, Walden University
PRAC 6635: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
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:
Physical exam: if applicable
Diagnostic results:
Assessment
Mental Status Examination:
Differential Diagnoses:
Reflections:
PRECEPTOR VERFICIATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
References
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