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WEEK 7 ASSIGNMENT 2: COMPREHENSIVE PSYCHIATRIC EVALUATION
NOTE And PATIENT CASE PRESENTATION, PART 2
Judith Asika
College of Nursing-PMHNP, Walden University
PRAC 6645: Psychotherapy with Multiple Modalities Practicum
Dr. Oyewole, Daniel
04/13/2025
, Subjective:
Client Background: Pt’s Name: T. T. Age: 65 Race: Spanish Gender: Male
Diagnosis: Bipolar Disorder, Anxiety Disorder, and PTSD
CC (chief complaint): “I struggle with trust and have no relationships with those I live with.”
HPI: T.T., a 65-year-old Hispanic male, presents for his initial intake at the clinic. He has a
history of Bipolar Disorder, Anxiety Disorder, and PTSD and has been previously hospitalized
and was raped during hospitalization. He reports being sexually abused by his dad, a history of
suicide 8 years ago, and cognitive impairment, isolation, and avoidance, although he
communicates logically. The client recalls going clubbing during his father’s abuse, and seven of
his siblings ran away from home. He currently lives with eight other people but rarely leaves the
house, spending most of his time at home. At 17, he moved to another state to escape his trauma.
This is his first therapy session outside of hospital stays, and he has never shared his trauma with
anyone. He has five children, with his oldest being 16. Referred by his primary care provider,
The client mentioned that one sister died by suicide, and several siblings are deceased. He
struggles with trust and has no relationships with those he lives with. Due to time constraints,
more information is needed before creating a treatment plan, and a follow-up intake is scheduled
in 14 days. He agrees with the plan.
Past Psychiatric History:
Psychiatric History: The client was diagnosed with Bipolar Disorder, Anxiety Disorder, and
PTSD and was hospitalized previously. He was sexually abused by his father and raped during
© 2022 Walden University Page 2 of 15
WEEK 7 ASSIGNMENT 2: COMPREHENSIVE PSYCHIATRIC EVALUATION
NOTE And PATIENT CASE PRESENTATION, PART 2
Judith Asika
College of Nursing-PMHNP, Walden University
PRAC 6645: Psychotherapy with Multiple Modalities Practicum
Dr. Oyewole, Daniel
04/13/2025
, Subjective:
Client Background: Pt’s Name: T. T. Age: 65 Race: Spanish Gender: Male
Diagnosis: Bipolar Disorder, Anxiety Disorder, and PTSD
CC (chief complaint): “I struggle with trust and have no relationships with those I live with.”
HPI: T.T., a 65-year-old Hispanic male, presents for his initial intake at the clinic. He has a
history of Bipolar Disorder, Anxiety Disorder, and PTSD and has been previously hospitalized
and was raped during hospitalization. He reports being sexually abused by his dad, a history of
suicide 8 years ago, and cognitive impairment, isolation, and avoidance, although he
communicates logically. The client recalls going clubbing during his father’s abuse, and seven of
his siblings ran away from home. He currently lives with eight other people but rarely leaves the
house, spending most of his time at home. At 17, he moved to another state to escape his trauma.
This is his first therapy session outside of hospital stays, and he has never shared his trauma with
anyone. He has five children, with his oldest being 16. Referred by his primary care provider,
The client mentioned that one sister died by suicide, and several siblings are deceased. He
struggles with trust and has no relationships with those he lives with. Due to time constraints,
more information is needed before creating a treatment plan, and a follow-up intake is scheduled
in 14 days. He agrees with the plan.
Past Psychiatric History:
Psychiatric History: The client was diagnosed with Bipolar Disorder, Anxiety Disorder, and
PTSD and was hospitalized previously. He was sexually abused by his father and raped during
© 2022 Walden University Page 2 of 15
