Chief compliant(CC) Joshua's hyperactive and attentional difficulties have been exhibited both at school and at home. HISTORY: Joshua is a Hispanic or Latino 10-year-old boy. This evaluation was requested because mother is worried about patient's aggressive behavior toward his younger brother and ADHD symptoms. Mother report that patient was diagnosed at age 6 by pediatrician with ADHD, medication was started at that time (mother unable to remember name) until age 9. Mother stopped administering medication because it caused decrease appetite, insomnia and weight loss. Patient is not currently taking any medication at this time. Behavior Described In: Symptoms/ behavior Joshua exhibits symptoms of inattention. He reports difficulty sustaining attention. His mind wanders or he forgets. He does not seem to listen when spoken to directly. He often needs directions repeated. Joshua is easily distracted by noises. by the radio. by other people. Joshua needs supervision or frequent redirection. He has a short attention span. Joshua exhibits signs of hyperactivity. He exhibits restlessness or fidgety behavior. This behavior is evident during school hours. He tends to frequently leave his seat. He is easily bored and changes activities frequently. Joshua 's excessive movement has been noted. He is fidgety or squirms when required to sit still for a period of time. He frequently jumps or climbs. Joshua exhibits signs of impulsive behavior. He frequently interrupts others. He often acts in a reckless manner. He has difficulty accepting limits. Joshua has other exhibited symptoms. He exhibits stubborn or willful behavior. EXAM: Joshua appears flat, inattentive, distracted, normal weight, He exhibits speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are intact. Affect is appropriate, full range, and congruent with mood. Associations are intact and logical. There are no apparent signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process. Associations are intact, thinking is logical, and thought content appears appropriate. Suicidal ideas or intentions are denied. Homicidal ideas or intentions are denied. There are signs of anxiety. A short attention span is evident. Judgment appears to be poor. Insight into problems appears to be poor. He is easily distracted. Joshua is restless. Joshua is fidgety. There is physical hyperactivity. Joshua displayed defiant behavior during the examination. Joshua made poor eye contact during the examination. Vocabulary and fund of knowledge indicate cognitive functioning in the normal range. Cognitive functioning and fund of knowledge are intact and age appropriate. Short- and long-term memory are intact, as is ability to abstract and do Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation Comprehensive psychiatric evaluations are a way to reflect on your practicum experiences and connect the experiences ...

1. Chief compliant(CC) Joshua's hyperactive and attentional
difficulties have been exhibited both at school and at home.
HISTORY: Joshua is a Hispanic or Latino 10-year-old boy. This
evaluation was requested because
mother is worried about patient's aggressive behavior toward his
younger brother and ADHD
symptoms. Mother report that patient was diagnosed at age 6 by
pediatrician with ADHD,
medication was started at that time (mother unable to remember
name) until age 9. Mother stopped
administering medication because it caused decrease appetite,
insomnia and weight loss. Patient
is not currently taking any medication at this time.
Behavior Described In:
Symptoms/ behavior Joshua exhibits symptoms of inattention.
He reports difficulty sustaining attention. His mind
wanders or he forgets. He does not seem to listen when spoken
to directly. He often needs
directions repeated. Joshua is easily distracted by noises. by the
radio. by other people. Joshua
needs supervision or frequent redirection. He has a short
attention span.
Joshua exhibits signs of hyperactivity. He exhibits restlessness
or fidgety behavior. This
behavior is evident during school hours. He tends to frequently
leave his seat. He is
easily bored and changes activities frequently. Joshua 's
excessive movement has been noted. He
is fidgety or squirms when required to sit still for a period of
time. He frequently jumps or climbs.
Joshua exhibits signs of impulsive behavior. He frequently
interrupts others. He often acts
in a reckless manner. He has difficulty accepting limits.
Joshua has other exhibited symptoms.

2. He exhibits stubborn or willful behavior.
EXAM: Joshua appears flat, inattentive, distracted, normal
weight, He exhibits speech that is
normal in rate, volume, and articulation and is coherent and
spontaneous. Language skills are
intact. Affect is appropriate, full range, and congruent with
mood. Associations are intact and
logical. There are no apparent signs of hallucinations,
delusions, bizarre behaviors, or other
indicators of psychotic process. Associations are intact,
thinking is logical, and thought content
appears appropriate. Suicidal ideas or intentions are denied.
Homicidal ideas or intentions are
denied. There are signs of anxiety. A short attention span is
evident. Judgment appears to be
poor. Insight into problems appears to be poor. He is easily
distracted. Joshua is restless. Joshua is
fidgety. There is physical hyperactivity. Joshua displayed
defiant behavior during the examination.
Joshua made poor eye contact during the examination.
Vocabulary and fund of knowledge indicate
cognitive functioning in the normal range. Cognitive
functioning and fund of knowledge are intact
and age appropriate. Short- and long-term memory are intact, as
is ability to abstract and do
Assignment 2: Comprehensive Psychiatric Evaluation and
Patient Case Presentation
Comprehensive psychiatric evaluations are a way to reflect on
your practicum experiences and connect the experiences to the
learning you gain from your weekly Learning Resources.
Comprehensive notes, such as the ones required in this
practicum course, are often used in clinical settings to document
patient care.
For this Assignment, you will document information about a
patient that you examined during the last 5 weeks, using the

3. Comprehensive Psychiatric Evaluation Template provided. You
will then use this note to develop and record a case presentation
for this patient.
To Prepare
Select a patient that you examined during the last 5 weeks.
Review prior resources on the disorder this patient has.
It is recommended that you use the Kaltura Personal Capture
tool to record and upload your assignment.
Conduct a Comprehensive Psychiatric Evaluation on this patient
using the template provided in the Learning Resources. All
psychiatric evaluations must be signed, and each page must be
initialed by your Preceptor. When you submit your document,
you should 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 SafeAssign. 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.
Assignment
Present the full case. Include 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.
Report normal diagnostic results as the name of the test and

4. “normal” (rather than specific value). Abnormal results should
be reported as a specific value.
Be succinct in your presentation, and do not exceed 8 minutes.
Address the following:
Subjective: What details did the patient provide regarding their
personal and medical history? What are their symptoms of
concern? How long have they been experiencing them, and what
is the severity? How are their symptoms impacting their
functioning?
Objective: What observations did you make during the interview
and review of systems?
Assessment: What were your differential diagnoses? Provide a
minimum of three (3) possible diagnoses. List them from
highest to lowest priority. What was your primary diagnosis,
and why?
Reflection notes: What would you do differently in a similar
patient evaluation?
Week 4 Lab Assignment: Differential Diagnosis for Skin
Conditions
1:
2:
3.
4.
5.
© 2021 Walden University
Week 4
Skin Comprehensive SOAP Note Template

5. Patient Initials: _______ Age: _______
Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Health Maintenance:
Immunization History:
Significant Family History:
Review of Systems:
General:
HEENT:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:

6. Musculoskeletal:
Neurological:
Psychiatric:
Skin/hair/nails:
OBJECTIVE DATA:
Physical Exam:
Vital signs:
General:
HEENT:
Neck:
Chest/Lungs:.
Heart/Peripheral Vascular:
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
Diagnostic results:
ASSESSMENT:
PLAN: This section is not required for the assignments in this
course (NURS 6512), but will be required for future courses.
© 2021 Walden University
Page 2 of 3

7. Comprehensive SOAP Exemplar
Purpose: To demonstrate what each section of the SOAP note
should include. Remember that Nurse Practitioners treat
patients in a holistic manner and your SOAP note should reflect
that premise.
Patient Initials: _______ Age: _______
Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Eddie Myers is a 58 year old
African American male who presents today with a productive
cough x 3 days, fever, muscle aches, loss of taste and smell for
the last three days. He reported that the “cold feels like it is
descending into his chest and he can’t eat much”. The cough is
nagging and productive. He brought in a few paper towels with
expectorated phlegm – yellow/green in color. He has associated
symptoms of dyspnea of exertion and fatigue. His Tmax was
reported to be 100.3, last night. He has been taking Tylenol
325mg about every 6 hours and the fever breaks, but returns
after the medication wears off. He rated the severity of her
symptom discomfort at 8/10.
Medications:
1.) Norvasc 10mg daily
2.) Combivent 2 puffs every 6 hours as needed
3.) Advair 500/50 daily
4.) Singulair 10mg daily
5.) Over the counter Tylenol 325mg as needed
6.) Over the counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhinitis
symptoms

8. Allergies:
Sulfa drugs - rash
Cipro-headache
Past Medical History (PMH):
1.) Asthma
2.) Hypertension
3.) Osteopenia
4.) Allergic rhinitis
5.) Prostate Cancer
Past Surgical History (PSH):
1.) Cholecystectomy 1994
2.) Prostatectomy 1986
Sexual/Reproductive History:
Heterosexual
Personal/Social History:
He has never smoked
Dipped tobacco for 25 years, no longer dipping
Denied ETOH or illicit drug use.
Immunization History:
Covid Vaccine #1 3/2/2021 #2 4/2/2021 Moderna
Influenza Vaccination 10/3/2020
PNV 9/18/2018
Tdap 8/22/2017
Shingles 3/22/2016
Significant Family History:
One sister – with diabetes, dx at age 65
One brother--with prostate CA, dx at age 62. He has 2
daughters, both in 30’s, healthy, living in nearby neighborhood.

9. Lifestyle:
He works FT as Xray Tech; widowed x 8 years; lives in the city,
moderate crime area, with good public transportation. He is a
college grad, owns his home and financially stable.
He has a primary care nurse practitioner provider and goes for
annual and routine care twice annually and as needed for
episodic care. He has medical insurance but often asks for drug
samples for cost savings. He has a healthy diet and eating
pattern. There are resources and community groups in his area
at the senior center but he does not attend. He enjoys golf and
walking. He has a good support system composed of family and
friends.
Review of Systems:
General: + fatigue since the illness started; + fever, no chills or
night sweats; no recent weight gains of losses of significance.
HEENT: no changes in vision or hearing; he does wear glasses
and his last eye exam was 6 months ago. He reported no history
of glaucoma, diplopia, floaters, excessive tearing or
photophobia. He does have bilateral small cataracts that are
being followed by his ophthalmologist. He has had no recent ear
infections, tinnitus, or discharge from the ears. He reported no
sense of smell. He has not had any episodes of epistaxis. He
does not have a history of nasal polyps or recent sinus infection.
He has history of allergic rhinitis that is seasonal. His last
dental exam was 1/2020. He denied ulceration, lesions,
gingivitis, gum bleeding, and has no dental appliances. He has
had no difficulty chewing or swallowing.
Neck: Denies pain, injury, or history of disc disease or
compression..
Breasts:. Denies history of lesions, masses or rashes.

10. Respiratory: + cough and sputum production; denied
hemoptysis, no difficulty breathing at rest; + dyspnea on
exertion; he has history of asthma and community acquired
pneumonia 2015. Last PPD was 2015. Last CXR – 1 month ago.
CV: denies chest discomfort, palpitations, history of murmur;
no history of arrhythmias, orthopnea, paroxysmal nocturnal
dyspnea, edema, or claudication. Date of last ECG/cardiac work
up is unknown by patient.
GI: denies nausea or vomiting, reflux controlled, Denies abd
pain, no changes in bowel/bladder pattern. He uses fiber as a
daily laxative to prevent constipation.
GU: denies change in her urinary pattern, dysuria, or
incontinence. He is heterosexual. No denies history of STD’s or
HPV. He is sexually active with his long time girlfriend of 4
years.
MS: he denies arthralgia/myalgia, no arthritis, gout or limitation
in her range of motion by report. denies history of trauma or
fractures.
Psych: denies history of anxiety or depression. No sleep
disturbance, delusions or mental health history. He denied
suicidal/homicidal history.
Neuro: denies syncopal episodes or dizziness, no paresthesia,
head aches. denies change in memory or thinking patterns; no
twitches or abnormal movements; denies history of gait
disturbance or problems with coordination. denies falls or
seizure history.
Integument/Heme/Lymph: denies rashes, itching, or bruising.
She uses lotion to prevent dry skin. He denies history of skin

11. cancer or lesion removal. She has no bleeding disorders,
clotting difficulties or history of transfusions.
Endocrine: He denies polyuria/polyphagia/polydipsia. Denies
fatigue, heat or cold intolerances, shedding of hair,
unintentional weight gain or weight loss.
Allergic/Immunologic: He has hx of allergic rhinitis, but no
known immune deficiencies. His last HIV test was 2 years ago.
OBJECTIVE DATA
Physical Exam:
Vital signs: B/P 144/98, left arm, sitting, regular cuff; P 90 and
regular; T 99.9 Orally; RR 16; non-labored; Wt: 221 lbs; Ht:
5’5; BMI 36.78
General: A&O x3, NAD, appears mildly uncomfortable
HEENT: PERRLA, EOMI, oronasopharynx is clear
Neck: Carotids no bruit, jvd or thyromegally
Chest/Lungs: Lungs pos wheezing, pos for scattered rhonchi
Heart/Peripheral Vascular: RRR without murmur, rub or gallop;
pulses+2 bilat pedal and +2 radial
ABD: nabs x 4, no organomegaly; mild suprapubic tenderness –
diffuse – no rebound
Genital/Rectal: pt declined for this exam
Musculoskeletal: symmetric muscle development - some age
related atrophy; muscle strengths 5/5 all groups.
Neuro: CN II – XII grossly intact, DTR’s intact
Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no
palpable nodes
Diagnostics/Lab Tests and Results:
CBC – WBC 15,000 with + left shift
SAO2 – 98%

12. Covid PCR-neg
Influenza- neg
Radiology:
CXR – cardiomegaly with air trapping and increased AP
diameter
ECG
Normal sinus rhythm
Spirometry- FEV1 65%
Assessment:
Differential Diagnosis (DDx):
1.) Asthmatic exacerbation, moderate
2.) Pulmonary Embolism
3.) Lung Cancer
Primary Diagnoses:
1.) Asthmatic Exacerbation, moderate
PLAN: [This section is not required for the assignments in this
course, but will be required for future courses.]
© 2021 Walden University
Page 4 of 4
© 2021 Walden University
Page 3 of 4
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2019). Seidel's guide to physical examination:
An interprofessional approach (9th ed.). St. Louis, MO: Elsevier
Mosby.

13. · Chapter 9, “Skin, Hair, and Nails”
This chapter reviews the basic anatomy and physiology of skin,
hair, and nails. The chapter also describes guidelines for proper
skin, hair, and nails assessments.
Colyar, M. R. (2015). Advanced practice nursing procedures.
Philadelphia, PA: F. A. Davis.
Credit Line: Advanced practice nursing procedures, 1st Edition
by Colyar, M. R. Copyright 2015 by F. A. Davis Company.
Reprinted by permission of F. A. Davis Company via the
Copyright Clearance Center.
This section explains the procedural knowledge needed pr ior to
performing various dermatological procedures.
Chapter 1, “Punch Biopsy”
Chapter 2, “Skin Biopsy”
Chapter 10, “Nail Removal”
Chapter 15, “Skin Lesion Removals: Keloids, Moles, Corns,
Calluses”
Chapter 16, “Skin Tag (Acrochordon) Removal”
Chapter 22, “Suture Insertion”
Chapter 24, “Suture Removal”
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced
health assessment and clinical diagnosis in primary care (6th
ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical
Diagnosis in Primary Care, 6th Edition by Dains, J.E.,
Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby.

14. Reprinted by permission of Mosby via the Copyright Clearance
Center.
Chapter 28, “Rashes and Skin Lesions”
This chapter explains the steps in an initial examination of
someone with dermatological problems, including the type of
information that needs to be gathered and assessed.
Note: Download and use the Student Checklist and the Key
Points when you conduct your assessment of the skin, hair, and
nails in this Week’s Lab Assignment.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2019). Skin, hair, and nails: Student checklist.
In Seidel's guide to physical examination (9th ed.). St. Louis,
MO: Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th
Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B.
S., & Stewart, R. W. Copyright 2019 by Elsevier Health
Sciences. Reprinted by permission of Elsevier Health Sciences
via the Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2019). Skin, hair, and nails: Key points. In
Seidel's guide to physical examination: An interprofessional
approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th
Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B.
S., & Stewart, R. W. Copyright 2019 by Elsevier Health
Sciences. Reprinted by permission of Elsevier Health Sciences
via the Copyright Clearance Center.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd
ed.). Philadelphia, PA: F. A. Davis.
· Chapter 2, "The Comprehensive History and Physical Exam"

15. (Previously read in Weeks 1 and 3)
VisualDx. (2021). Clinical decision support: For professionals.
Retrieved July 16, 2021,
from http://www.skinsight.com/professionals
This interactive website allows you to explore skin conditions
according to age, gender, and area of the body.
Bonifant, H., & Holloway, S. (2019). A review of the effects of
ageing on skin integrity and wound healing. British Journal of
Community Nursing, 24(Sup3), S28–S33.
https://doi.org/10.12968/bjcn.2019.24.sup3.s28
Document: Skin Conditions (Word document)
This document contains images of different skin conditions.
You will use this information in this week’s Discussion.
Document: Comprehensive SOAP Exemplar (Word document)
Document: Comprehensive SOAP Template (Word document)
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date

16. NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation
Template
CC (chief complaint):
HPI:
Past Psychiatric History:
· General Statement:
· Caregivers (if applicable):
· Hospitalizations:
· Medication trials:
· Psychotherapy or Previous Psychiatric Diagnosis:
Substance Current Use and History:
Family Psychiatric/Substance Use History:
Psychosocial History:
Medical History:
· Current Medications:
· Allergies:
· Reproductive Hx:
ROS:
· GENERAL:
· HEENT:
· SKIN:
· CARDIOVASCULAR:
· RESPIRATORY:
· GASTROINTESTINAL:
· GENITOURINARY:
· NEUROLOGICAL:
· MUSCULOSKELETAL:
· HEMATOLOGIC:
· LYMPHATICS:
· ENDOCRINOLOGIC:
Physical exam: if applicable

17. Diagnostic results:
Assessment
Mental Status Examination:
Differential Diagnoses:
Reflections:
References
© 2020 Walden University
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