NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation

 
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Substance Current Use and History
: The patient reports a history of occasional alcohol use. However, she denies any illicit substance or tobacco use. She also denies vaping.  Family Psychiatric/Substance Use History: She denies any family mental health issues, and collaborative information about her parents is not reachable during this assessment. There is no history of substance use in the family. 
Psychosocial History: The patient reports a good relationship with her family members who closely monitor her. She reports that her uncle, Boris is supportive. She is currently going to school but is struggling with concentrating on her school work because of her anxiety Medical History: ?Current Medications: The patient is currently taking the following medications:?
Abilify 5 mg orally daily ?Pristiq 50 mg orally once daily?Zoloft 50 mg PO qDay ?Allergies: The patient has no Known Drug Allergies. She also denies any food, environmental, or seasonal allergies. ?Reproductive Hx: The patient is sexually active heterosexual and has painless regular menses Review of Systems: (ROS)General: The patient admits to being fatigued, tired, lethargic, and has anhedonia. She denies night sweats or chills. However, she reports problems falling and staying asleep.HEENT: No tinnitus, hearing difficulties, ringing of the ears, congestion, sore throat, abnormalmouth movements