lOMoAR cPSD| 66549320
1
Running header: Week 3 Assignment: Assessing & Diagnosing Patients with Mood Disorders
Week 3 Assignment: Assessing and Diagnosing Patients with Mood Disorders
College of Nursing - PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
September 18, 2022
Subjective:
CC (chief complaint): “I'm wound up. Lost my temper.”
HPI: A.C is a 54-year-old Caucasian female presents, alone, for psychiatric evaluation for being
“wound up… Lost my temper”. Stated that she had lost her temper and pushed her son down.
Stated that 3 months ago she was up for promotion and did not get it. She was not happy about it
and began to worry, and loose sleep, and lose self-esteem, stated “My husband and children
deserve better. Even the job I’m doing is at risk, in jeopardy”. She currently takes 2 to 4 drinks to
, lOMoAR cPSD| 66549320
Week 3 Assignment: Assessing & Diagnosing Patients with Mood Disorders 2
help sleep, states that she tried her husbands sleeping pills which did not work. Reported
symptoms include loss of sleep, feelings of exhaustion, memory loss, irritability and worry
Past Psychiatric History:
• General Statement: The patient presents alone for psychiatric evaluation.
• Caregivers (if applicable): Not applicable
• Hospitalizations: None
• Medication trials: None
• Psychotherapy or Previous Psychiatric Diagnosis: has had suicidal ideations, without any
plans or attempts.
Substance Current Use and History: 2 to 4 drinks daily, took husband’s sleeping pill.
Family Psychiatric/Substance Use History: Brother has depression; mother has history of
being a “functioning alcoholic”.
Psychosocial History: A.C. was raised in Trenton, New Jersey, where she was born and raised
along with her father, two brothers, and mother, who passed away when she was 12 years old in
an MVA. Resides with her husband and their two sons, who are twins. Currently residing in
Sioux Falls, South Dakota, and employed full-time by a financial organization as a contract
negotiator, holds an MBA. No legal history, no trauma history, and no violence history.
Medical History: “Fatty Liver”
• Current Medications: None indicated
• Allergies: Codiene
• Reproductive Hx: Two teenage twin sons.
ROS:
• GENERAL: No weight loss, fever, chills, weakness, or fatigue
1
Running header: Week 3 Assignment: Assessing & Diagnosing Patients with Mood Disorders
Week 3 Assignment: Assessing and Diagnosing Patients with Mood Disorders
College of Nursing - PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
September 18, 2022
Subjective:
CC (chief complaint): “I'm wound up. Lost my temper.”
HPI: A.C is a 54-year-old Caucasian female presents, alone, for psychiatric evaluation for being
“wound up… Lost my temper”. Stated that she had lost her temper and pushed her son down.
Stated that 3 months ago she was up for promotion and did not get it. She was not happy about it
and began to worry, and loose sleep, and lose self-esteem, stated “My husband and children
deserve better. Even the job I’m doing is at risk, in jeopardy”. She currently takes 2 to 4 drinks to
, lOMoAR cPSD| 66549320
Week 3 Assignment: Assessing & Diagnosing Patients with Mood Disorders 2
help sleep, states that she tried her husbands sleeping pills which did not work. Reported
symptoms include loss of sleep, feelings of exhaustion, memory loss, irritability and worry
Past Psychiatric History:
• General Statement: The patient presents alone for psychiatric evaluation.
• Caregivers (if applicable): Not applicable
• Hospitalizations: None
• Medication trials: None
• Psychotherapy or Previous Psychiatric Diagnosis: has had suicidal ideations, without any
plans or attempts.
Substance Current Use and History: 2 to 4 drinks daily, took husband’s sleeping pill.
Family Psychiatric/Substance Use History: Brother has depression; mother has history of
being a “functioning alcoholic”.
Psychosocial History: A.C. was raised in Trenton, New Jersey, where she was born and raised
along with her father, two brothers, and mother, who passed away when she was 12 years old in
an MVA. Resides with her husband and their two sons, who are twins. Currently residing in
Sioux Falls, South Dakota, and employed full-time by a financial organization as a contract
negotiator, holds an MBA. No legal history, no trauma history, and no violence history.
Medical History: “Fatty Liver”
• Current Medications: None indicated
• Allergies: Codiene
• Reproductive Hx: Two teenage twin sons.
ROS:
• GENERAL: No weight loss, fever, chills, weakness, or fatigue
