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
Subjective:
CC (chief complaint): “ The government are watching me with the drone without my consent”
HPI: J. A is a 43-year-old African American who was recently discharged from the hospital due to aggression, threatening to shoot his neighbor, a suicide attempt by cutting his wrist, and visual and auditory hallucinations. He mentioned that his neighbor works for the government and they always watch him with a drone. He was at the hospital for 13 days and was on medication the whole time. He was referred by the doctor to seek psychiatric help after hospital discharge. According to his older sister, he has not been the same since he came back from his last military tour 8 months ago but has not had any fights with the neighbors until recent time.
He sometimes has some road rage, but she never know it was an effect of his military time. During the assessment, he mentioned that he has been having some flashbacks and is triggered by the smell of burning flames, bbq, traffic, or loud noise. He barely gets out of the house due to fear of being monitored. He rates his depression on a scale of 1-10 ( 10 being the worst), he rated it to 7/10), and anxiety 6/10. He drinks occasionally and smokes marijuana to help him cope or sleep. He was seeing a psychotherapist for depression and PTSD but was not on medication before his recent hospital admission. He has a good appetite. He sleeps about 3 to 4 hours at night due to nightmares but sometimes takes Benedryl to help him sleep.
Substance Current Use: Alcohol, Marijuana. Denies any other illicit drug use
Past psychiatric history: PTSD, depression
Medication trials and current medications: Respiradone 2 mg daily, Zoloft 50 mg daily, Celexa 10 mg daily, Lisinopril 10 mg daily, Atorvastatin 40 mg at bedtime.
Psychotherapy or previous psychiatric diagnosis: He has been seeing the psychotherapist for the past 3 months.
Family psychiatric history: No family history of mental health problems, suicide, or unknown death before 30 years old.
Medical History: HTN, HLD
Allergies: PCN
Reproductive Hx: He has two daughters from his ex-wife. He is sexually active, but not in any relationship.
Psychosocial: The patient was born and raised in Houston Texas, but moved down to East Texas After high school. He has two younger brothers and one older sister. He is currently staying with his sister. Both parents died years ago and he is in a good relationship with his siblings. He was married for 14 years with 2 daughters but divorced 2 years ago.
He has a high school diploma with some college classes. He joined the military while in college. He has emotional trauma from when he was in Afghanistan. One of his friends was burnt when they were in a convoy with a grenade. He has a legal issue with the law after he tried to kill his neighbor. No physical or head trauma. He used to enjoy going to football games with his brothers, and also like to ride a motorcycle with his friends.
ROS:
Objective:
Diagnostic results: N/A
Diagnostic results: N/A
Assessment:
Mental Status Examination: Mental Status Examination:
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