Video to use: https://video-alexanderstreet-com.eu1.proxy.openathens.net/watch/training-title-48

Name: Sarah Higgins
Gender: female
Age: 11 years old
T- 97.4 P- 58 R 14 98/62 Ht 4’5 Wt 65lbs
Background: no history of treatment, developmental milestones met on time, vaccinations up to
date. Sleeps 9-10hrs/night, meals are difficult as she has hard time sitting for meals, she does get
proper nutrition per PCP. she has a younger brother. lives with her parents in Washington,
D.C. No hx of head trauma

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Student Name
College of Nursing-PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date

Subjective:
CC (chief complaint):
HPI:
Past Psychiatric History:
β€’ General Statement:
β€’ Caregivers (if applicable):
β€’ Hospitalizations:
β€’ Medication trials:
β€’ Psychotherapy or Previous Psychiatric Diagnosis:
Substance Current Use and History:
Family Psychiatric/Substance Use History:
Psychosocial History:
Medical History:

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β€’ Current Medications:
β€’ Allergies:
β€’ Reproductive Hx:
ROS:
β€’ GENERAL:
β€’ HEENT:
β€’ SKIN:
β€’ CARDIOVASCULAR:
β€’ RESPIRATORY:
β€’ GASTROINTESTINAL:
β€’ GENITOURINARY:
β€’ NEUROLOGICAL:
β€’ MUSCULOSKELETAL:
β€’ HEMATOLOGIC:
β€’ LYMPHATICS:
β€’ ENDOCRINOLOGIC:
Objective:
Physical exam: if applicable
Diagnostic results:
Assessment:
Mental Status Examination:
Differential Diagnoses:
Reflections:
References