Comprehensive Psychiatric Evaluation 3: Major Depressive Disorder

COMPREHENSIVE PSYCHIATRIC EVALUATION 31Comprehensive Psychiatric Evaluation 3Shumeka Hill, RN, PNP-AC, FNP-BCLiberty University OnlineNURS754Dr. TolliverFebruary 13, 2023

COMPREHENSIVE PSYCHIATRIC EVALUATION 32Comprehensive Psychiatric Evaluation 3CC(chief complaint): I am depressed, I can’t sleep. I feel embarrassed about myself and mysituation. I just want to sit in the sun, and I don’t want to do anything. I have no energy. I don’thave the strength to do things with my family. I have pain in my back and arm. I cry a lot. I amnervous, I have to drive I don’t let my wife drive because I was hit by a car by a woman and Ifear that will happen if my wife drives. I get very angry. I am easily irritable and stressed out. Ihaven’t seen my family because of COVID and if feel incompetent I can’t help my wife with theduties at home and kids.HPI:51-year old Hispanic Spanish male present with an interpreter. The patient is alert andoriented x4 with minimal eye contact attitude is cooperative, the mood is depressed, thoughtcontent is normal, the patient denies hallucinations, denies suicidal/homicidal, and insightjudgment is intact. The patient complains that he is depressed and cannot sleep.Past Psychiatric History:· General Statement: The patient’s psychiatric history is unremarkable.· Caregivers (if applicable): The patient has no caregiver.· Hospitalizations: The patient’s history of hospitalization is unremarkable.· Medication trials: The patient has no medications for a psychiatric condition.· Psychotherapy or Previous Psychiatric Diagnosis: The patient has no history of psychotherapyfor any mental condition.Substance Current Use and History: The patient’s history of substance use is unremarkable.

COMPREHENSIVE PSYCHIATRIC EVALUATION 33Family Psychiatric/Substance Use History: The patient stated he is married. He does havechildren,4 of them. The patient states he does not drink alcohol. The patient states he does notuse tobacco. The patient state he does not use drugs prescription or street drugs.