CASE OF MARA PAULA

INTAKE DATE: July xxxx

IDENTIFYING/DEMOGRAPHIC DATA: Mara Paula is a 33-year-old Hispanic female. She has two daughters, aged 7 and 4. She works full time as an executive assistant but is currently furloughed and has been since March. Mara Paula has a live in boyfriend, Tomaz. They have been together 9 years.

CHIEF COMPLAINT/PRESENTING PROBLEM: "I am wondering if I still have a job since I have not been called back yet. I am the primary breadwinner and unemployment will be running out soon." The job situation is on my mind, adding to all the other areas of concern I have had over the years about my family, my children, my relationship, and taking care of my house.

HISTORY OF PRESENT ILLNESS: Mara Paula has been working at the same company since she was 18 years old. She loves her job and believes she does it very well, which is how she moved up in the company. Now that she is not working she finds herself not wanting to do much of anything with her children or partner. Her focus is on if she will be called back to work or permanently discharged which is affecting everything in her life. She feels on edge all the time and her skin seems to crawl. Mara Paula's reports her anxiety is so high now with all the stress she is under.

Mara Paula reports that she has always had a tendency to be anxious and has always been apprehensive with expectations of what may happen. Growing up her parents called her their "little worry wart". She ignores her parents now since she has learned this is who she is and has stopped trying to change. Mara Paula reports she was never a good sleeper, twisting and turning all night, waking up, and having difficulty falling back to sleep. Mara Paula's current situation about her job has just added to her irritability and tension. She was never a very active since she does tire easily. This has gotten in the way with her life but Mara Paula makes sure this does not interfere with her job.

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

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

PAST MEDICAL HISTORY: Mara Paula denies any physical illnesses. This has been confirmed by her primary care physician. She has had several blood tests over the past several years, so many that her anxiety goes very high when she knows one is coming. She recently went for an antibody test for Covid 19 and did not realize it would be a blood test. When she saw the needle her anxiety increased so much she began trembling and sweating. She thought she was going to throw up as her heart pounded. Mara Paula rolled her eyes as she reports this has happened on several occasions. There were no previous significant medical issues in her past.

FAMILY MEDICAL AND PSYCHIATRIC HISTORY: Mara Paula 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 intellectual disability from a young age. The family's focus has always been on taking care of her older brother. Mara Paula reports feeling responsible for her extended family and needs to be involved with their issues especially since her parents are aging. She recalls growing up and always feeling responsible for her family members.

CURRENT FAMILY ISSUES AND DYNAMICS: Mara Paula and Tomaz have never married. She is concerned that at this point marriage would interfere with their relationship. Mara Paula maintains the family house and is the primary breadwinner which is why she is so concerned now about the employment situation. Mara Paula's financial issues are continuing to increase her stress.

Eight years ago, Mara Paula began a romantic relationship with Tomaz after a long term work friendship. Tomaz divorced nine years ago. Mara Paula believed she was finally happy in a relationship. Tomaz moved into her home soon after their romantic relationship began. Tomaz promised he would take care of her financially for the rest of her life. They have two children together.

MENTAL STATUS EXAM: Mara Paula presented as a casually dressed, meticulously groomed woman who appeared her stated age of 33. She had a fixed, mood congruent expression on her face. Motor activity was normal. Mood appeared slightly depressed. Speech was soft, content was adequate. Thought processes were goal-directed, logical but at times distracted. There was no evidence of delusions. Mara Paula was oriented to time, place, and person. During the intake, Mara Paula's thoughts would jump around at times. She noted that over the past several months she has had an inability to concentrate. Digit span was 7 forward and 4 in reverse. She was able to calculate serial 7's. Recent and remote memory appeared intact. Intelligence appeared above average and fund of knowledge was excellent. All factual questions were answered correctly. Mara Paula was able to abstract similarities and proverbs with detail and accuracy. Ordinary social and personal judgment was appropriate.

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 include the plus sign in your diagnosis. Instead, write the indicated items next to each other.

Code + Name + Specifier (appears on its own first line) Z code (appears on its own line next with its name written next to the code)

• Explain how you support the diagnosis by specifically identifying the criteria from the case study.
  • Describe in detail how the client's symptoms match up with the specific diagnostic criteria for the disorder (or all the disorders) that you finally selected for the client. You do not need to repeat the diagnostic code in the explanation.
• Identify the differential diagnosis you considered.
• Explain why you excluded this diagnosis/diagnoses.
• Explain the specific factors of culture that are or may be relevant to the case and the diagnosis, which may include the cultural concepts of distress.
• Explain why you chose the Z codes you have for this client.
  • Remember: When using Z codes, stay focused on the psychosocial and environmental impact on the client within the last 12 months.