Comprehensive Psychiatric Evaluation on Heroin Addiction

Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
PRAC 6635: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
CC (chief complaint): Follow up for symptoms assessment
HPI: C.V. is a 17-year-old female patient who came to the clinic accompanied by her foster mother with a chief complaint of heroin addiction. She currently confirms taking IV heroin for the past two years. Her current feelings started showing after being abused sexually by her uncle at the age of 5 and 12 years.
Past Psychiatric History:
General Statement: The patient entered treatment for SUD and PSTD at 17 but abused heroin for the past two years.
Caregivers (if applicable): Foster mother
Hospitalizations: None
Medication trials: recommended to rehab, but she declined.
Psychotherapy or Previous Psychiatric Diagnosis: She has a history of PSTD. She was recommended to rehab, but she refused
Substance Current Use and History:
C.V., a 17-year-old female patient, arrived at the facility with her foster mother and had a heroin addiction as her main complaint. She has been consuming 8–10 stamp packets of heroin every day for the past two years. Rehab was suggested to the patient, but she declined. She attests to low self-worth, depression, hopelessness, helplessness, and inadequate understanding. Her uncle has a past of sexually abusing her between the ages of 5 and 12. To cope with the experience, she first began smoking marijuana, then moved on to painkillers, and finally turned to heroin. She acknowledges engaging in self-destructive behavior, such as cutting herself, and a past of PTSD.
Family Psychiatric/Substance Use History: The mother is an alcoholic, while the father died at the age of 25 years from an opioid overdose.
Psychosocial History: C.V. felt worthless, helpless, and hopeless and had low self-esteem. She displays poor insight and confirms a history of PTSD and self-injurious behaviors.
Medical History:
Current Medications: monthly S.C. injection (Sublocade) for heroin addiction and sertraline (Zoloft) for PTSD.
Allergies: None
Reproductive Hx: None
ROS:
Vital Signs: None
General signs:
HEENT: None 
Breasts: None
Respiratory: None 
Cardiovascular/Peripheral Vascular: None 
Gastrointestinal: None
Genitourinary: None
Musculoskeletal: None
Psychiatric: None
Neurological:
Hematologic: None
Endocrine: None
Immunologic: None
Physical exam: if applicable
Temp: 37°C
B.P.: 119/80 mmHg
HR: 68beats per minute
R:118 breaths per minute
Pain: none
Diagnostic results:
GAD-7 is a diagnostic test that was used to examine the patient. The score was 17. The score was greater than ten showing that the client had GAD. It also means the patient has severe anxiety levels.
Mental health Assessment
MSE: Physical examination will be performed but not every visit. The patient is cooperative, and there are no signs of acute stress. She is dressed appropriately, and psychomotor activities are normal. Howe...