The diagnosis should appear on one line in the following order.?Note: Do not include the plus sign in your diagnosis. Instead, write the indicated items next to each other.Code + Name + Spe

CASE of NAHLA

INTAKE DATE: May xxxx

IDENTIFYING/DEMOGRAPHIC DATA: Nahla is a 29-years-old, single, heterosexual, African American female. Nahla lives with her boyfriend, Dion, of 4 years. She wants to get married ,but her boyfriend does not believe he is ready yet since he is three years younger than her. Nahla is a Certified Public Accountant, who loves her job. Dion is a manager for a gym franchise.

CHIEF COMPLAINT/PRESENTING PROBLEM: “My job is flexible and I can work from home often but lately my focus has been in other areas and I just have trouble getting to work”

HISTORY OF PRESENT ILLNESS: Nahla concerns herself about many things, which is not new to her and she finds that by scrubbing her home clean is her best therapy to ease her concerns . Nahla reports that germs have been a regular concern of hers since adolescence, when she learned in health classes about the risks of serious diseases including sexual transmittable disease. There are times when she looks at the house and it triggers her and within minutes she has intense discomfort feeling dizzy, sweating, feels nauseous, and trouble breathing. She is able to calm herself down in a few minutes. Nahla presented with meticulous grooming. She is challenged by her time management sometimes, when she finds herself scrubbing the house clean daily. This worries her in case she gets a visitor and the house is not in order as she would like it. She sometimes has arguments with Dion to help more around the house. The amount of time it takes to scrub the house clean delays her daily schedule.

PAST PSYCHIATRIC HISTORY: Nahla has never been for therapy before and decided to attend now because her life seems to be spinning out of control. She has always been organized and liked a clean home, for as long as she can remember. Dion is not as invested in that. She remembers always keeping her room clean as a teen which was very different than her friends. She remembers sometimes going to friends homes that had messy rooms. She would get dizzy and nauseous at their homes also when she saw that. There was a time that she actually was so concerned about getting dizzy and throwing up that she stopped visiting friends for months and would only meet them in public areas.

SUBSTANCE USE HISTORY: Nahla reports drinking socially. She tried marijuana in college several times but did not like it. She denies any other drug use

PAST MEDICAL HISTORY: Nahla had the usual childhood illnesses but has not had any severe illnesses in adulthood.

FAMILY MEDICAL AND PSYCHIATRIC HISTORY: Nahla shared that when she was 2-years-old her mother died from cancer. She denies any psychiatric history in the family although she does not know her mothers’ family very well.

CURRENT FAMILY ISSUES AND DYNAMICS: Nahla shared that she was raised in the military; her father is an army officer. Nahla’s father remarried and she gets along well with her stepmother. She has two half brothers from that union. She has travelled all over the world living on military bases mostly. She has a very close relationship with her father. She knows they were raised in the “military” fashion but believes it has benefitted her over the years.

MENTAL STATUS EXAM: Nahla is oriented to time, place, and person. She is professionally dressed, and her stated age. She presents with some anxiety in the interview. Motor activity is appropriate. Speech is clear. There is no evidence of delusions or hallucinations. Nahla intelligence appears above average.

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