evaluationmm.docx - NRNP/PRAC 6635 Comprehensive...

  • Walden University
  • PRAC 6635
  • Essay
  • currymegh
  • 7
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NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation CC (chief complaint): I am depressed, I can’t sleep. I feel embarrassed about myself and my situation. I just want to sit in the sun, and I don’t want to do anything. I have no energy. I don’t have the strength to do things with my family. I have pain in my back and arm. I cry a lot. I am nervous, I have to drive I don’t let my wife drive because I was hit by a car by a woman and I fear that will happen if my wife drives. I get very angry. I am easily irritable and stressed out. I haven’t seen my family because of COVID and if feel incompetent I can’t help my wife with the duties at home and kids. HPI: 51-year old Hispanic Spanish male present with an interpreter. The patient is alert and oriented x4 with minimal eye contact attitude is cooperative, the mood is depressed, thought content is normal, the patient denies hallucinations, denies suicidal/homicidal, and insight judgment 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 psychotherapy for any mental condition. Substance Current Use and History: The patient’s history of substance use is unremarkable. Family Psychiatric/Substance Use History: The patient stated he is married. He does have
children,4 of them. The patient states he does not drink alcohol. The patient states he does not use tobacco. The patient state he does not use drugs prescription or street drugs. Psychosocial History: The patient stated he is married. He does have children,4 of them. He does customary work duties as a concrete finisher especially setting forms and applying concrete. Medical History: The patient is currently taking medications for high blood pressure, high cholesterol, and blood clots.

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