NRNP 6635 Case History Reports
Use these case histories to supplement the information about the patients in the video case
studies.
Table of Contents
Week 3: Mood Disorders………………………………………………………………………………………….. 2
Training Title 2 ……………………………………………………………………………………………………………….2
Training Title 8 ……………………………………………………………………………………………………………….2
Training Title 18 ……………………………………………………………………………………………………………..3
Training Title 28 ……………………………………………………………………………………………………………..3
Training Title 38 ……………………………………………………………………………………………………………..3
Training Title 43 ……………………………………………………………………………………………………………..4
Training Title 150 ……………………………………………………………………………………………………………4
Training Title 118 ……………………………………………………………………………………………………………5
Training Title 144 ……………………………………………………………………………………………………………5
Week 4: Anxiety Disorders, PTSD, and OCD …………………………………………………………………. 6
Training Title 15 ……………………………………………………………………………………………………………..6
Training Title 21 ……………………………………………………………………………………………………………..6
Training Title 37 ……………………………………………………………………………………………………………..7
Training Title 40 ……………………………………………………………………………………………………………..7
Training Title 55 ……………………………………………………………………………………………………………..7
Training Title 85 ……………………………………………………………………………………………………………..8
Training Title 95 ……………………………………………………………………………………………………………..8
Week 7 Schizophrenia and Other Psychotic Disorders; Medication-Induced Movement
Disorders ………………………………………………………………………………………………………………. 9
Training T
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template
AND
the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide.
In the Subjective section, provide:
· Chief complaint
· History of present illness (HPI)
· Past psychiatric history
· Medication trials and current medications
· Psychotherapy or previous psychiatric diagnosis
· Pertinent substance use, family psychiatric/substance use, social, and medical history
· Allergies
· ROS
· Read rating descriptions to see the grading standards!
In the Objective section, provide:
· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
· Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
· Read rating descriptions to see the grading standards!
In the Assessment section, provide:
· Results of the mental status examination,
presented in paragraph form.
· At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis.
Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case
.
· Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (
demonstrate critical thinking beyond confidentiality and consent for treatment
!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)
EXEMPLAR BEGINS HERE
CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patie
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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