Objective:

To develop a comprehensive psychiatric evaluation report for Nina, integrate all aspects of her background, symptoms, DSM-5-TR diagnosis, and treatment plan. Additionally, students will present the treatment plan to demonstrate their understanding of clinical assessment, diagnosis, and treatment planning in psychiatric practice.

Instructions:

Using the detailed case study of Nina throughout this course, students are required to create a comprehensive psychiatric evaluation report. The report should be structured as follows:

1. Identifying Data:
   • Provide basic demographic information about Nina, including age, gender, occupation, marital status, children, living situation, and immigration status.
2. Chief Complaint:
   • Summarize Nina's main concerns and reasons for seeking help.
3. History of Present Illness:
   • Detail the onset, duration, and progression of Nina's current symptoms.
   • Include information on how her symptoms affect her daily life and any coping mechanisms she has tried.
4. Past Psychiatric History:
   • Describe any previous psychiatric diagnoses, treatments, hospitalizations, and outcomes.
5. Substance Use/Abuse:
   • Document Nina's history of substance use, including types of substances used, duration, and any effects on her mental health.
6. Past Medical History:
   • Summarize any significant medical history, surgical history, medications, allergies, and immunizations.
7. Family Psychiatric History:
   • Provide information on any family history of psychiatric disorders or substance use.
8. Developmental and Social History:
   • Include details about Nina's upbringing, education, employment, relationships, hobbies, and social support system.
9. Review of Systems (ROS):
   • Conduct a systematic review of Nina's physical health across various systems to identify any additional concerns.
10. Mental Status Examination (MSE):
    • Document Nina's appearance, behavior, speech, mood and affect, thought process, thought content, perception, cognition, insight, and judgment.
11. DSM-5-TR Diagnosis:
    • Provide a diagnosis based on the DSM-5-TR criteria, including all relevant diagnoses with corresponding ICD-10 codes.
12. Treatment Plan:
    • Develop a comprehensive treatment plan, including pharmacological interventions, substance use management, psychotherapy, social support, and follow-up strategies.

Format and Submission Guidelines for Report:

1. The report should be 4–6 pages in length and double-spaced. It should include the link to your presentation as well. 
2. Use 12-point, Times New Roman font, and 1-inch margins.
3. Include headings for each section to organize the report clearly.
4. Cite any references used in APA Style.

Treatment Plan Presentation:

• Prepare a 5- to 7-minute presentation summarizing the treatment plan. Review the Getting Started With Panopto document for details on creating a video. You will copy the "share" link to your presentation in "My Panopto Video" and include that in your written report. Do not submit the actual video in the "assignment submission," as you cannot submit your report simultaneously. 
• The presentation should cover:
  • An overview of Nina's background and presenting issues
  • The DSM-5-TR diagnosis and rationale
  • Detailed explanation of the treatment plan, including:
    • Pharmacological interventions
    • Substance use management
    • Psychotherapy approaches
    • Social support strategies
    • Follow-up and monitoring plan
  • Expected outcomes and goals for Nina's treatment
• Use PowerPoint or similar software to create visual aids for your presentation.
• Record your presentation and include the link to your presentation in the report that you submit above. Do not submit the actual video in the "assignment submission" because you cannot submit your report simultaneously.