NRNP 6635: Psychopathology and Diagnostic Reasoning
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NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
CC (chief complaint):
Past Psychiatric History:
Substance Current Use and History:
Family Psychiatric/Substance Use History:
Physical exam: if applicable
Mental Status Examination:
CASE STUDY – WEEK # 7
Name: Mrs. L.R.
Gender: female Age: 28 years old T- 97.6 P- 87 R 18161/86Ht 5’6Wt217 lbs
C.C. “I’m feeling sad and anxious every day, with no energy, crying constantly and at night I’s sleeping only few hours. I don’t want to spend time with my newborn, my 4 years old daughter or my husband. Lately I feel like people is looking at me constantly”
Background: Recently had her second child five months ago. Currently married; stay at home mother after working in private firm for 7 years.
Grew up with both parents, mother with hx. of depression and hypothyroidism, father with hx. ofhypertension and myocardial infarction (MI)at 62 y/o, both retired.
Sister lives in Orlando, FL with hx. of depression and diabetes, single no children and brother in last year of high school, no previous medical or psychiatric history.
Completed education through bachelor’s level, studying accounting and business administration. No previous suicidal gestures; has uncle who committed suicide via GSW. She denied drugs/alcohol; uncle was opioid abuser.
Hx of HTN-prescribed labetalol 100mg twice daily, admits to missing doses due to forgetting. No legal hx. Allergies: lidocaine and penicillin.
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