SOCW 6090 week 5

INTAKE DATE: May 2019

IDENTIFYING/DEMOGRAPHIC DATA: Lanelle is a 29-year-old, single, heterosexual, African American female. Lanelle 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. Lanelle is a Certified Public Accountant, who loves her job. Dion is a manager for a gym franchise.

CHIEF COMPLAINT/PRESENTING PROBLEM: I am worried about my job since charges were pressed against me from Grants Department store for not paying for a lipstick.

HISTORY OF PRESENT ILLNESS: Lanelle has admitted that she has taken small things previously that “the store doesn’t care much about.” She realizes she can afford these small items, but the excitement she experiences and tension right before taking an item is fun when she gets away with the item. “Everyone takes a lipstick or so” she expresses. Lanelle states she concerns herself about many things, which is not new to her. Since she could remember she was the concerned person in her family about her siblings, her parents, family finances. Her mom used to tell her not to concern herself with things beyond her control. Lanelle 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 worries it triggers her and within minutes she knows intense discomfort is coming, feeling dizzy, sweating, feeling nauseous, and having trouble breathing. She can tell when the discomfort is coming and is able to calm herself down in a few minutes. Lanelle and Dion entertain often and Lanelle worries she may get visitors and the house is not in order as she would like it. She sometimes has arguments with Dion to help more around the house.

PAST PSYCHIATRIC HISTORY: Lanelle has never been for therapy before and decided to attend now because her life seems to be spinning out of control. She states the restlessness, trouble sleeping and anxiety has always been a part of who she is which is why she never needed to go to therapy. She admits that all this is distressing and sometime interferes with her life especially with Dion.

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

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

FAMILY MEDICAL AND PSYCHIATRIC HISTORY: Lanelle reports no significant family medical or psychiatric history.

CURRENT FAMILY ISSUES AND DYNAMICS: Lanelle shared that she was raised in the military; her father is an army officer. She has two brothers. 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: Lanelle presented with meticulous grooming. Lanelle is oriented to time, place, and person. She is professionally dressed and looks her stated age. She presents with some anxiety in the interview as well as restlessness. She states that this is normal for her so she is used to it. Motor activity is appropriate. Speech is clear. Lanelle does report being irritable due to here restlessness. There is no evidence of delusions or hallucinations. Lanelle’s intelligence appears above average.