Submit your diagnosis for the client in the case. Follow the guidelines below.The diagnosis should appear on one line in the following order.Note: Do not incl

CASE OF ISABELLA

INTAKE DATE: January xxxx

IDENTIFYING/DEMOGRAPHIC DATA: Isabella is a 23-year-old Hispanic female. She has two sons, aged 2 and 4, who live with her and her boyfriend, Tomaz. They have been together 5 years. She works full time as an executive secretary.

CHIEF COMPLAINT/PRESENTING PROBLEM: “I am in constant physical pain every day and can hardly walk and move. Even at night when I am in bed I am always in pain.” Isabella reports that even in the few moments the pain eases it is difficult for her to get sleep.

HISTORY OF PRESENT ILLNESS: Isabella has been suffering from physical pain for the past 18 months. She has been to many doctors for help. Isabella has been very concerned about her illness and wants to understand the causes of this pain. She believes it had something to do with having children. There has never been an accurate diagnosis. She has been given medication and steroids with no relief of her physical pain. Most recently, she had a full evaluation at the Mayo Clinic which had inconclusive results. One doctor at the Mayo clinic suggested she seek individual counseling, hoping this will help her physically as well. Isabella’s reports her anxiety is so high now with all the stress she is under.

PAST PSYCHIATRIC HISTORY: Isabella denies any past psychiatric history for herself. The only significant family history is her older brother’s diagnosis of Intellectual Disability.

SUBSTANCE USE HISTORY: Isabella reports drinking socially and very minimally. There is no evidence of substance use disorders in her family.

PAST MEDICAL HISTORY: Isabella has been ailing over the past 18 months with unidentified pain. There were no previous significant medical issues in her past.

FAMILY MEDICAL AND PSYCHIATRIC HISTORY: Isabella is the third child of four from her parents union. She has an older sister, a brother, and a younger sister. Her brother was diagnosed with an intellectual disability from a young age. The family’s focus has always been on taking care of her older brother. Her father died 6 years ago. Isabella lost her mother to dementia 6 months earlier than this intake. With the death of her mother, the responsibility of her brother has now been transferred to Isabella and her two sisters. Isabella reports feeling responsible for her extended family and needs to be involved with their issues. She recalls growing up and always feeling in turmoil. Since she was required to take care of her siblings, she thought it was time that she gets the attention she deserves.  

CURRENT FAMILY ISSUES AND DYNAMICS: Isabella likes to be involved with her siblings but they seem to get jealous of her all the time. They seem to blame her that others like her the best. She has had spats with her siblings when they seem to ignore her. Isabella cannot help that she is the sexiest sister in the family. She is always getting compliments from others all the time. Men especially seem to gravitate towards her which angers Tomaz. This is the reason why she has not married him.

Six years ago, while finishing high school, Isabella began a romantic relationship with Tomaz after a short friendship. Isabella believed she was finally happy in a relationship, especially since Tomaz is very attentive. Tomaz and Isabella moved in together soon after their romantic relationship began. Tomaz promised he would take care of her financially for the rest of her life. Now she finds him being very jealous of her friendships with others.

Isabella is feeling increased stress with the loss of her mother, the burden of care taking her older brother, and Tomaz’s jealousy of her male friends. She is finding herself fatigued due to this stress.

MENTAL STATUS EXAM: Isabella presented as a casually dressed (although very seductive for the interview), meticulously groomed woman who appeared her stated age of 23. She had a fixed, mood congruent expression on her face. Motor activity was normal. Mood appeared depressed and was dysphoric. Affect was constricted. Speech was guarded and soft, content was adequate. Isabella would go back and forth and become teary eyed (while looking at the interviewer for a reaction) then the tears would stop. Thought processes were shallow and the discussion lacked detail. There was no evidence of delusions. Isabella was oriented to time, place, and person. During the intake, Isabella’s thoughts would jump around and at times appeared very dramatic. Isabella noted that she has always “seen the world more intensely than others” and has run into bigger problems than others. Even in relationships she has always treated them with intensity even if others did not.

She noted that over the past several months she has had an inability to concentrate at work. She was unable to calculate serial 7's. Recent and remote memory appeared intact. Intelligence appeared average and fund of knowledge was normal. All factual questions were answered correctly. Ordinary social and personal judgment seemed inappropriate in some of her responses.

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