Week 5 6635 Prac
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Select a patient that you examined during the last 5 weeks. Review prior resources on the disorder this patient has.
In Week 5: Assignment 2, Part 1, you submitted the Video Evaluation Presentation.
In Week 5: Assignment 2, Part 2, you will submit the documentation.
Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. There is also a completed exemplar document in the Learning Resources so that you can see an example of the types of information a completed evaluation document should contain. All psychiatric evaluations must be signed, and each page must be initialed by your Preceptor. You will submit your document in Week 5 Assignment, Part 2 area and you will include the complete Comprehensive Psychiatric Evaluation as a Word document, as well as a PDF/images of each page that is initialed and signed by your Preceptor. You must submit your document using Turn It In. Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.
Develop a video case presentation, based on your progress note of this patient, that includes chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis, including differentials that were ruled out.
Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.
Ensure that you have the appropriate lighting and equipment to record the presentation.
This is my patient:
40 year old male presents with PTSD, and Adjustment Disorder. Patient is recently released from prison due to robbing a pharmacy due to an addiction issue. Patient is in a toxic relationship for about 6 months now. Family does not approve. Girlfriend spending all his money. She is very controlling, and has made threats that if she can’t have him, nobody can along with she has a gun and she can set him up to go back to prison with his parole officer. Patient feels trapped. Patient sleeps well, he does drink a lot of coffee though out the day, but still feels tired. His mood is alright, appetite is ok. His other stressors are his father has stage 4 cancer and his mother has dementia. Vit D was suggested. Prescribed medications are Clonazepam 0.5 mg BID and ½ TID, and Venlafaxine XR 300. Will follow up with patient in January.
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
College of Nursing-PMHNP, Walden University
PRAC 6635: Psychopathology and Diagnostic Reasoning
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
Patient Initials: J.S. Age: 40 years Sex: Male Race: Caucasian Date: 01/01/2026
CC (chief complaint): “I feel trapped in my relationship and feel stressed about everything in my life.”
HPI : J.S. is a 40-year-old Caucasian male reporting for psychiatric follow-up on PTSD and adjustment disorder. He has recently come out of prison due to a robbery in a pharmacy in connection with previous substance use and is on parole. He states more distress associated with six-month toxic relationship involving financial exploitation, emotional abuse, control, and threat involving a gun and interference with parole causing him to feel scared and imprisoned, but there is no physical violence. He has PTSD symptoms such as hypervigilance, intrusive thoughts, and anxiety involving the perceived threats without nightmares or flashbacks. His mood is described as “alright,” but is emotionally exhausted; appetite and sleep duration are normal, but he complains of fatigue in the daytime and reports excessive caffeine consumption. Denies suicidal or homicidal ideation. Other stressors are that his father has stage IV cancer and his mother has dementia. He denies any serious side effects, is medication compliant, and was adviced to take vitamin D.
Past Psychiatric History :
G eneral Statement: The patient initially received psychiatric care when he was in his early 30s due to legal substance use related problems. There was an increase in formal psychiatric care in incarceration.
C aregivers (if applicable): Not applicable.
H ospitalizations: One past inpatient psychiatric hospitalization at the age of 34 because of substance-induced mood symptoms and detoxification. Denies committing suicide attempts or self-harm. Denies homicidal behavior.
M edication trials:
Sertraline: trialed in the past, minimal benefit.
Fluoxetine: discontinued due to emotional blunting.
P sychotherapy or P revious Psychiatric Diagnosis:
Diagnosed with PTSD and substance use disorder during incarceration.
Participated in cognitive behavioral therapy and trauma-focused group therapy while incarcerated; found therapy moderately helpful.
Currently not engaged in psychotherapy.
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
Substance Current Use and History:
Caffeine: Heavy use, approximately 6–8 cups of coffee daily.
Alcohol: Occasional use, 1–2 beers weekly; denies binge drinking.
Illicit substances: History of opioid misuse related to pharmacy robbery; reports abstinence for over one year.
Nicotine: Smokes approximately ½ pack per day.
Denies history of withdrawal seizures or delirium tremens.
Family Psychiatric/Substance Use History:
Father: No psychiatric history; currently diagnosed with stage IV cancer.
Mother: Dementia, no known prior psychiatric history.
No known family history of suicide.
One uncle with alcohol use disorder.
Psychosocial History: The patient was born and brought up in the Midwest and raised by both parents. He has a younger sister whom he rarely has time to interact with. He is in a volatile housing situation with his girlfriend and is divorced without children. He finished high school and has a bit of vocational education. He is currently unemployed and on parole searching to work. His criminal record is noteworthy due to a felony conviction, and he is still on strict parole compliance measures. His trauma history involves incarceration related trauma and continuous emotional abuse in his current relationship. He denies violent behavior history and notes that he is afraid of his personal safety because his partner threatens him.
Medical History: No chronic medical illnesses reported. No history of seizures or traumatic brain injury.
Current Medications :
Venlafaxine XR 300 mg PO daily – for PTSD and mood symptoms (2 years).
Clonazepam 0.5 mg PO BID and 0.25 mg PO TID PRN anxiety.
Vitamin D supplementation recommended (OTC).
Allergies :
Medications: No known drug allergies.
Food:
Environmental: Seasonal pollen – causes mild rhinorrhea.
Reproductive Hx : Denies sexual dysfunction. Heterosexual. Sexually active with current partner.
ROS :
General: Reports fatigue; denies fever, weight change.
HEENT: Denies headaches, vision changes, hearing loss.
Skin: No rashes or lesions.
Cardiovascular: Denies chest pain, palpitations.
Respiratory: Denies shortness of breath or cough.
Gastrointestinal: Denies nausea, vomiting, diarrhea.
Genitourinary: Denies urinary symptoms.
Neurological: Denies dizziness, syncope, weakness.
Musculoskeletal: Denies joint or muscle pain.
Endocrine: Denies heat/cold intolerance.
Psychiatric: Endorses anxiety, hypervigilance; denies SI/HI, hallucinations, or manic symptoms.
Physical exam:
General: Well-nourished male, appears stated age, mildly tense posture.
HEENT: Head atraumatic; pupils equal and reactive; mucous membranes moist.
Cardiovascular: Regular rate and rhythm; no murmurs.
Respiratory: Clear breath sounds bilaterally; unlabored respirations.
Neurological: Alert, oriented ×4; no focal deficits observed.
Diagnostic results :
Recent basic metabolic panel within normal limits (per patient report).
Vitamin D level pending due to fatigue complaints.
PHQ-9: Mild depressive symptoms.
GAD-7: Moderate anxiety.
PTSD Checklist (PCL-5): Elevated, consistent with PTSD.
Assessment
Mental Status Examination:
J.S. is a 40-year-old Caucasian male who looks his stated age and is well-groomed in casual clothes. He is cooperative, somewhat guarded, tense in posture and a bit restless. Speech is fluent and consistent with normal rate and tone. He reports his mood as “Alright,” but stressed, and his affect as anxious and constricted, which is not congruent with the stated mood. The thought processes are goal-oriented and logical without delusions, obsessions, or paranoia and the focus of thought content is to relationships and legal stressors. He denies hallucinations or mania. He is alert and oriented to person, place, time, and situation with intact memory and sufficient concentration. His awareness of his mental health conditions and relational stressor factors is decent and his judgment is slightly impaired as shown by his continued engagement in a high-risk emotionally abusive relationship despite understanding the possible consequences. Denies the presence of suicidal or homicidal ideation, intent or plan at this time.
Differential Diagnoses:
Post-Traumatic Stress Disorder (Primary Diagnosis): Post-Traumatic Stress Disorder is a trauma-related condition marked by persistent distress following exposure to a traumatic event (Mann et al., 2024). DSM-5-TR criteria involve exposure to the trauma, intrusive symptoms, hyperarousal, and dysfunctional impairment that persists more than one month (Du et al., 2022). The patient has a history of incarceration-related trauma, hypervigilance, intrusive thoughts, and anxiety linked to perceived threats as lasting more than one year, which supports this diagnosis.
Adjustment Disorder with Anxiety: Adjustment Disorder and Anxiety is an emotional distress that is responsive to stressful events that happen during a three-month period and is resolved after six months when the stressor ceases to occur (Bambrah et al., 2022). This diagnosis is considered because of the recent stressors like confinement, illness in the family, and conflict in relationships. The diagnosis is however eliminated as the major diagnosis since the symptoms experienced by the patient are chronic, go beyond the normal duration of adjustment disorder and can be better attributed to PTSD.
Generalized Anxiety Disorder (GAD): Generalized Anxiety Disorder is an excessive, uncontrollable worry that occurs on more than one domain with a physical and cognitive manifestation that lasts at least six months (Munir & Takov, 2022). Despite the patient having chronic worry, tension and fatigue, this diagnosis is eliminated since his anxiety is rather situational and trauma-related than pervasive and generalized in various life situations.
Primary Diagnosis: Post-Traumatic Stress Disorder
The diagnosis of Post-Traumatic Stress Disorder is appropriate since the patient has a definite history of exposure to traumatic experiences associated with incarceration and continued perception of threat accompanied with consequent symptoms of hypervigilance, intrusive thoughts and anxiety that persist significantly beyond one year and create functional distress. These are trauma-specific symptoms, which are worsened by situations that remind him of the lack of control and safety and cannot be adequately explained by a mood disorder, substance use, or a transient response to recent stressors. The long-term duration, symptomatology, and correlation to the DSM-5-TR criteria indicate that PTSD is the most approppriate and comprehensive diagnosis for this patient NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template.
Reflections:
This case demonstrates the complexity of dealing with patients with a psychiatric issue that is complicated by legal intervention and the instability of the psychosocial situation. I concur with my preceptor’s PTSD diagnosis but would emphasize more on intimate partner violence risk assessment and safety planning. Ethical issues are not confined to confidentiality. There exist plausible threats of firearms and fraud with parole that increase the duty-to-protect and mandatory-reporting factors as well as cooperation with legal systems. Consideration should be made over benzodiazepine prescribing considering substance use history and parole status (Volkow & Blanco, 2023). This patient is strongly affected by social determinants of health such as unstable housing, unemployment, legal restrictions, and caregiving stress. Trauma-informed care, substance relapse prevention, caffeine reduction, sleep hygiene, and linking to domestic violence resources are some areas of health promotion that need to be addressed NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template. It would be necessary to support culturally and developmentally adequate psychoeducation, psychotherapy referral (trauma-focused CBT) and coordination with parole services. In the event of independent management, I would focus on benzodiazepines tapering, increased psychotherapy involvement, social work-based safety planning, and social work-based environmental risk reduction to enhance long-term outcomes.
PRECEPTOR VERFICIATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
References
Bambrah, V., Wyman, A., Friedman, E., & Eastwood, J. D. (2022). Examining the longitudinal associations between adjustment disorder symptoms and boredom during COVID-19. Behavioral Sciences , 12 (9), 311. https://doi.org/10.3390/bs12090311
Du, J., Diao, H., Zhou, X., Zhang, C., Chen, Y., Gao, Y., & Wang, Y. (2022). Post-traumatic stress disorder: A psychiatric disorder requiring urgent attention. Medical Review , 2 (3), 219–243. https://doi.org/10.1515/mr-2022-0012
Mann, S. K., Marwaha, R., & Torrico, T. J. (2024, February 25). Posttraumatic stress disorder (PTSD) . PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559129/
Munir, S., & Takov, V. (2022). Generalized anxiety disorder . National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441870/
Volkow, N. D., & Blanco, C. (2023). Substance use disorders: A comprehensive update of classification, epidemiology, neurobiology, clinical aspects, treatment and prevention. World Psychiatry , 22 (2), 203–229. https://doi.org/10.1002/wps.21073 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
