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CASE OF DANIELA INTAKE DATE: December xxxx Diagnosis: F45.1 …
CASE OF DANIELA
INTAKE DATE: December xxxx
Diagnosis:
F45.1 Somatic Symptom Disorder, with predominant pain
F34.1 Persistent Depressive Disorder
Z63.0 Relationship Distress with Spouse or Intimate Partner
IDENTIFYING/DEMOGRAPHIC DATA: Daniela is a 53-years-old Hispanic female. She has two adult sons, aged 27 and 24, who both live with her. She works full time as an executive secretary. Daniela has a live in boyfriend, Tomaz. They have been together 8 years.
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.” Daniela reports that even in the few moments the pain eases it is difficult for her to get sleep.
HISTORY OF PRESENT ILLNESS: Daniela has been suffering from physical pain for the past 18 months. She has been to many doctors for help. Daniela has been very concerned about her illness and wants to understand the causes of this pain. 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 Clinical which had inconclusive results. One doctor at the Mayo clinic suggested she seek individual counseling, hoping this will help her physically as well. Daniela’s reports her anxiety is so high now with all the stress she is under.
PAST PSYCHIATRIC HISTORY: Daniela denies any past psychiatric history for herself. The only significant family history is her older brother’s diagnosis of Intellectual Disability.
SUBSTANCE USE HISTORY: Daniela reports drinking socially and very minimally. There is no evidence of substance use disorders in her family.
PAST MEDICAL HISTORY: Daniela 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: Daniela 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. Her father died 6 years ago. Daniela 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 Daniela and her two sisters. Daniela reports feeling responsible for her extended family and needs to be involved with their issues
CURRENT FAMILY ISSUES AND DYNAMICS: Daniela divorced 17 years ago after 12 years of marriage. The marriage was tumultuous. Her husband was addicted to pornography and had several affairs. Daniela denies any physical abuse but reports a lot of emotional abuse that she sustained from her husband. Daniela maintained the family house after the divorce but had very little money to support the household and her two sons. Daniela’s financial issues continued to increase her stress over the years.
Eight years ago, Daniela began a romantic relationship with Tomaz after a long term work friendship. Tomaz divorced nine years ago. Daniela 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.
Four years ago, Tomaz was diagnosed with terminal cancer. Following the diagnosis, Tomaz became a spendthrift and purchased very large items such as trucks, motorcycles, and ATV’s. Daniela was feeling increased sadness with the loss of her mother, the burden of care taking her brother, Tomaz’s diagnosis and his increased spending of his money. She always found she had low energy
MENTAL STATUS EXAM: Daniela presented as a casually dressed, meticulously groomed woman who appeared her stated age of 53. 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. Thought processes were goal-directed and logical. There was no evidence of delusions. Daniela was oriented to time, place, and person. She noted that over the past several months she has had an inability to concentrate at work. Digit span was 7 forward and 4 in reverse. She was unable 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. Daniela was able to abstract similarities and proverbs with detail and accuracy. Ordinary social and personal judgment was appropriate.
Diagnosis Explained:
F45.1 Somatic Symptom Disorder, with predominant pain
A. B.1, 3 C.
F34.1 Persistent Depressive Disorder
A. B. 2, 3, 5 C. D. E. F. G. H.
Z63.0 Relationship Distress with Spouse or Intimate Partner
