NRNP 6675 2023 GUARANTEED GRADED A+
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6665: PMHNP Care Across the Lifespan I
Faculty Name
Assignment Due Date
, NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
Subjective:
CC (chief complaint): “I felt overstimulated, sensory overload”
HPI: AD is a 24 year old African America female who presents for medical management
follow-up for depression, dissociative identity disorder, and anxiety. She has a diagnosis
for major depressive disorder, generalized anxiety disorder with panic attacks,
dissociative identity disorder, and post-traumatic stress disorder. The patient has a
history of verbal and physical abuse from her biological mother and step father. She has
also a history of sexual assault from several foster homes where she has lived.
Substance Current Use: Patient denies current and past substance use
Medical History:
Current Medications: 12.5mg PO QAM and Q1300 for mood stabilization
Allergies: onipons, mushrooms, and codeine
Reproductive Hx: LMP: 1/3/2023, not pregnant, contraceptive used is barrier
method, sexually active; vaginal, history of sexual trauma
ROS:
GENERAL: pt. denies weight loss, fever, chills, or weakness
HEENT: Head: denies trauma or headaches Eyes: vision is intact, no blurred
vision or exudate from eyes Ears: hearing is intact, no pain, swelling, or exudate
Nose: Nasal cavity is clear, no lesions or congestion Throat: No swelling,
difficulty swallowing, or lymphadenomegaly
SKIN: Denies itching, rash, or acne
CARDIOVASCULAR: Denies palpitations and murmurs, pt. reports palpitations
during panic attacks
RESPIRATORY: No shortness of breath, coughing, or wheezing. Pt. reports
shortness of breath when experiencing a panic attack
GASTROINTESTINAL: Denies diarrhea, nausea, and changes in bowel
movements
GENITOURINARY: Denies hematuria, polyuria, and incontinence
NEUROLOGICAL: pt. is fidgety and appears nervous, denies history of seizures,
numbing, and tingling
MUSCULOSKELETAL: Denies joint pain, stiffness, or loss of balance, maintains
upright posture and appropriate gait
HEMATOLOGIC: Denies history of anemia, easy bruising, and bleeding
LYMPHATICS: No history of splenectomy, no swollen nodes
ENDOCRINOLOGIC: denies polyuria, heat or cold intolerance, or excessive
thirst
© 2021 Walden University Page 2 of 5
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6665: PMHNP Care Across the Lifespan I
Faculty Name
Assignment Due Date
, NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
Subjective:
CC (chief complaint): “I felt overstimulated, sensory overload”
HPI: AD is a 24 year old African America female who presents for medical management
follow-up for depression, dissociative identity disorder, and anxiety. She has a diagnosis
for major depressive disorder, generalized anxiety disorder with panic attacks,
dissociative identity disorder, and post-traumatic stress disorder. The patient has a
history of verbal and physical abuse from her biological mother and step father. She has
also a history of sexual assault from several foster homes where she has lived.
Substance Current Use: Patient denies current and past substance use
Medical History:
Current Medications: 12.5mg PO QAM and Q1300 for mood stabilization
Allergies: onipons, mushrooms, and codeine
Reproductive Hx: LMP: 1/3/2023, not pregnant, contraceptive used is barrier
method, sexually active; vaginal, history of sexual trauma
ROS:
GENERAL: pt. denies weight loss, fever, chills, or weakness
HEENT: Head: denies trauma or headaches Eyes: vision is intact, no blurred
vision or exudate from eyes Ears: hearing is intact, no pain, swelling, or exudate
Nose: Nasal cavity is clear, no lesions or congestion Throat: No swelling,
difficulty swallowing, or lymphadenomegaly
SKIN: Denies itching, rash, or acne
CARDIOVASCULAR: Denies palpitations and murmurs, pt. reports palpitations
during panic attacks
RESPIRATORY: No shortness of breath, coughing, or wheezing. Pt. reports
shortness of breath when experiencing a panic attack
GASTROINTESTINAL: Denies diarrhea, nausea, and changes in bowel
movements
GENITOURINARY: Denies hematuria, polyuria, and incontinence
NEUROLOGICAL: pt. is fidgety and appears nervous, denies history of seizures,
numbing, and tingling
MUSCULOSKELETAL: Denies joint pain, stiffness, or loss of balance, maintains
upright posture and appropriate gait
HEMATOLOGIC: Denies history of anemia, easy bruising, and bleeding
LYMPHATICS: No history of splenectomy, no swollen nodes
ENDOCRINOLOGIC: denies polyuria, heat or cold intolerance, or excessive
thirst
© 2021 Walden University Page 2 of 5
