NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric

Evaluation Template

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric

Evaluation Template

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric

Evaluation Template

Week # 7 Comprehensive Psychiatric Evaluation

College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II
January11th, 2023


1. Perform a thorough complete psychiatric evaluation.
2. Choose the best possible primary diagnosis.

3. Analyze the best pharmacology and nonpharmacological Options
4. Provide community resources.


CC (chief complaint): “I’m here because my doctors and mom are worried about my mood. I’m always sad, overwhelmed, and anxious about my new baby and I cry often. I am struggling with this new baby.”

K.A. is a 16-year-old Hispanic female that presents to the office today with her mother for initial intake. The patient verbalized that she had a baby two months ago but has been suffering from sadness, hopelessness, guilt, and frequent crying. She reports that she felt sad and depressed when she found out she was pregnant but that the feelings of worthlessness and helplessness with periods of anxiety have increased since giving birth two months ago. She states “sometimes I don’t want to get out of bed to do anything but now this baby is making it difficult for me able to do what I want. She feels guilty for letting her family down because had big hopes for her. She reports that when the baby cries she gets tremors, increased heart palpitations, and sweating spells. She also complains of frequent headaches, body aches, and tension. Mom reports that she is concerned with the client’s well-being because she is sad and cries when she fails to take care of the baby. Sometimes she does not sleep because she thinks something will happen to the baby. The client’s mom reports that she has to remind her several times to take a bath and groom herself otherwise she can stay in her pajamas for days. She forgets to provide care for the baby and is scared and anxious when the baby cries. The client denies suicide ideation or hallucinations. She denies any alcohol or substance use. She denies any past psychiatric history. She denies any family psychiatric history or hospitalizations.

Substance Current Use: Patient denies substance use, alcohol or cigarette smoking

Past Psychiatric History: K.A denies any past psychiatric history or hospitalization

General Statement: K.A. is sad, tearing up occasionally, and feels hopeless, worthless, withdrawn, and anxious at times.

Caregivers (if applicable): Mother

Hospitalizations: None

Medication trials: K.ANRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Week 7 Discussion GO
Walden University
PRAC 6675 Across the Lifespan
January 11, 2023


CC (chief complaint): the patient JP reports trouble dealing with anxiety, depression, anhedonia and worrying about school as well as lack of energy.

HPI: The patient JP is a 17-year-old caucasian male that presented to the clinic for a follow-up appointment for the management of his anxiety, depression, and lack of energy. He arrived at the office today with his mother. JP’s first sought treatment at the age of 15 related to his anxiety and depression. At this time, he started falling behind in school and had difficulty keeping up. At the age of 15, he was started on Zoloft, but after about six months did not see much improvement in the symptoms and stopped the medications. The patient has not seen another prescriber since the age of 15. The patient first presented to our clinic about three months ago and since then has been initiated on Effexor and has since been titrated to 112.5 milligrams PO qday. The patient reported an improvement in his symptoms when initiated on 37.5 milligrams qday but only started seeing efficacy when the dosage was titrated to 112.5 milligrams qday. The patient rates his mood to be a 6 out of 10 compared to previous scores of three on the last office visit.

Substance Current Use: JP denies any nicotine use. He does report that at the age of 16, he experimented with drinking alcohol socially with peers on the weekends. He stated that in one sitting, he would have ten beers. The patient states that he has not had any alcohol in approximately six months now. The patient denies any additional recreational drug use. the patient denies any caffeine use.

Medical History:

Current Medications: Effexor 112.5 mg PO qday

no known drug allergies, no known food or environmental allergies.

Reproductive Hx:
Denies current or previous sexual activity.


· GENERAL: the patient denies any recent weight loss or weight gain. The patient has no complaints of fevers or chills. The patient denies any changes in his energy levels. The patient reports that he’s able to sleep approximately 6 to 8 hours nightly without interruption.
· HEENT: The patient’s head is symmetrical with no obvious deformities. The patient has no discharge of the eyes, ears, or nose. Throughout the interview, is not noted that the patient had any productive cough or trouble breathing. The patient denies any history of head injuries. The patient also denies any visual disturbances, including double vision or blurry vision.
· SKIN: the patient’s skin is normal for ethnicity with no rash observed.
· CARDIOVASCULAR: The patient denies any chest pain or chest discomfort. There is no note of any edema in any extremities. The patient denies anNRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

College of Nursing-PMHNP, Walden University
PMHNP Across Lifespan II Pract-Winter 2022


CC (chief complaint): Attempted suicide

HPI: A.P. is an 24-year-old African American presenting with a chief complaint of attempted suicide. The patient was admitted for a cocaine overdose. The patient exhibits symptoms of short temper, irritability, mood swings, and intense anger. He also reports binge drinking and eating. The patient exhibits marked impulsivity and irrational behaviors. The patient’s mother says he mainly talks about death and threatens to jump off the balcony. She also reports that A.P. has episodes of variable moods that last for a few hours. A.P. reports experiencing recurrent thoughts of suicide and feeling worthless.

A.P. dropped out of college and stayed at home with his younger brother, who is physically disabled. The patient also has a pattern of intense relationships that do not last long. He recently ended his intimate relationship abruptly. He also cut family ties with his father and step-siblings and avoids his extended family members and friends. Additionally, the patient is distressed and wishes his suicide attempt was successful. The patient has a previous history of attempted suicide. He has had several burns and cuts on his arms. A.P. has also tried harming his younger brother when angry. He reports reckless driving when unable to control his anger. The patient has a DUI report and was convicted of physical violence when drunk. He lost his first job due to binge drinking and irrational behaviors.
The patient was diagnosed with depression at 18 years old. He was under antidepressants but discontinued therapy and treatment seven months ago after quitting college. A.P. has a family history of bipolar disorder. His maternal grandmother had a history of anxiety and depression. The patient’s maternal uncle has a history of cocaine abuse and died from an overdose. His father also smokes tobacco and has a history of diabetes. A.P. was exposed to unstable invalidating relationships in his childhood. He was raised by a single mother who had on-and-off intimate relationships. The patient also experienced abandonment at age 12. He reports temporarily living under foster care.

Substance Current Use: The patient smokes tobacco (2 packets per day) and abuses cocaine. He is also a binge drinker (7 bears per day). He has a history of marijuana abuse.

Medical History:

Current Medications: The patient is currently not under any medication or psychotherapy.

The patient is protein intolerant and experiences hives, itching, and eczema. He reports milk, eggs, and peanut allergies. He is also allergic to pet dander and exhibits nasal congestion and uncontrollable sneezing. He has no known drug allergies.


The goal is for the discussion forum to function as robust clinical conferences on the patients. Provide a response to 1 of the 3 discussion prompts that your colleagues provided in their video presentations. You may also provide additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient.

Questions for the third presentations

What additional nonpharmacological recommendations would you have for a patient suffering from major depressive disorder and or generalized anxiety disorder?

2. Do you agree with my preceptor’s recommendation to change his medication from Zoloft to Effexor? What other medications would you have considered prior to starting Effexor after the failed trial of Zoloft?
3. For patients suffering from major depressive disorder, how would your treatment plan differentiate from an adolescent to an adult?
4. What resources are available in your area to assist patients that are suffering from suicidal ideation or an exacerbation of their depressive symptoms?

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