wk7assgn2AnyanwuE(6635).pdf - Week (Seven): Assessing and...

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Week (Seven): Assessing and Diagnosing Patient with PsychoticElizabeth AnyanwuCollege of Nursing-PMHNP, Walden UniversityNRNP 6635: Psychopathology and Diagnostic ReasoningDr Billy Leonardo7/18/21
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation TemplateCC: This is a 45 yrs. old Hispanic male presents for psych evaluationHPI: Pt is a 45-year-old Hispanic male on a 5150 hold for DTS. Pt has a history of depressionand alcohol dependence and family history of bipolar disorder who is BIB family due todepressed mood, alcohol dependence and worsening suicidal ideation. Pt admits to SI withoutclear plan - "somehow" - and AH that are most pronounced at night. Pt denies VH/HI. Endorsesdepressed mood, inability to sleep without drinking alcohol (however denies fatigue despitesleep problems) and poor appetite/food intake in the setting of multiple environmental stressors(e.g., lost job waiting tables 1 year ago due to COVID, his house burned down two weeks agowhich led to alcohol relapse, which then led his wife leavinghim - she also left pt.’s adult kidsthat are diagnosed with bipolar disorder, which pt. believes was because of their mental illnesshx). He endorses h/o sleepless episodes without getting tired, during which he can sometimestalk faster/more than usual and those close to him say he is not making sense. Has h/o excessiverisk taking (e.g., driving while drunk - h/o DUI x2). Pt admits to h/o sexual trauma/rape inchildhood - denies flashbacks/nightmares/intrusive thoughts, however, appears increasinglyemotional/nearly tearful as denying these questions (pt guarded, suspect minimization). Ptreports he drinks at least a 12 pack per day of beer but denies history of alcohol withdrawalseizures and hospitalizations for alcohol withdrawal. He denies all other substance useadamantly. He reports he stopped cold turkey about a half year ago (around the time he was
diagnosed with COVID) and had severe anxiety/panic attacks for a couple days after stopping,but said he improved after that. He says AH were still present during 6-month period of sobrietyand shares that his kids also have AH (including his 10-year-old son). He endorses h/o HTN butdenies any other significant medical history.

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