The Assignment

Document the following for the family in the video, using the Comprehensive Evaluation Note Template:

• Chief complaint
• History of present illness
• Past psychiatric history
• Substance use history
• Family psychiatric/substance use history
• Psychosocial history/Developmental history
• Medical history
• Review of systems (ROS)
• Physical assessment (if applicable)
• Mental status exam
• Differential diagnosis—Include a minimum of three differential diagnoses and include how you derived each diagnosis in accordance with DSM-5-TR diagnostic criteria
• Case formulation and treatment plan
• Include a psychotherapy genogram for the family

Solution:NRNP-6645 Week 2 Assignment Family Assessment

NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Template

CC (chief complaint): “I feel depressed, I cannot move, I need them to come and visit me, spend a night with me”

HPI:

P.K. is a 40-year-old Iranian female presenting for psychiatric consultation for depression, chronic pain, and family relational conflict. She is currently prescribed pain medications following bilateral foot surgery failure and was referred by her outpatient therapist, Sandi, for psychiatric evaluation and medication management. P.K. reports persistent depressed mood, hopelessness, helplessness, and social isolation with symptom onset intensifying following failed bilateral foot surgeries that left her disabled and unemployed. Prior to her disability she functioned independently as a full-time caregiver. She endorses frequent and severe depressive episodes triggered by loneliness and interpersonal conflict with her adult children, who are her sole source of social support. She reports significant functional impairment in sleep, motivation, and daily activities. In addition to her current mood presentation, P.K. carries a substantial trauma history that appears to be contributing to her current psychiatric distress. She endured years of domestic violence and physical abuse perpetrated by her husband in Iran. She immigrated to the United States approximately 12 years ago, leaving behind her then 8-year-old daughter Shireen, who was subsequently physically and sexually abused by the father over the following decade. Approximately two to three years prior to this session, Shireen was reunited with the family, at which time she disclosed the full extent of the abuse. P.K. reports that she grieved this disclosure intensely, stating “when I heard about it, I was crying and crying for months,” and that while she believes she has moved through the acute grief, she acknowledges that the trauma remains persistently present, saying “it is always in my head.” She reports ongoing guilt related to her decision to leave Shireen behind, though she has framed it as a survival decision made under extreme duress. She demonstrates limited but present insight, some capacity for humor, and motivation to engage in treatment, having recently identified Weight Watchers as a community resource to support her physical and psychological wellbeing.

Past Psychiatric History:

• General Statement: P.K. has a history of depressive symptoms associated with chronic pain, trauma, and acculturative stress. She was referred by her therapist for psychiatric evaluation and medication management……

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