Case Study
Patient Demographic: Initial Intake:  Age: 32 Gender: Female Sexual Orientation: Bisexual Ethnicity: Caucasian Relationship Status: In a relationship Counseling Setting: Community mental health agency Type of Counseling: Individual via Telehealth
Mental Status Exam: Melanie is unkempt, looks tired and is casually dressed. Motor movements are within normal limits, eye contact is appropriate. Melanie reported passive suicidal ideation intermittently throughout her depressive episode as a means for escaping her feelings but has no plan or intent. Melanie reluctantly admits to several instances of past trauma which include losing her son’s father to a tragic car accident four years ago where her son witnessed him die, as well as having three other older children, all with separate fathers, with whom she has no contact. Her only support system is her boyfriend who takes great care of her and her son’s school, which provides help with his Individualized Education Plan.
Presenting Problem: Diagnosis: Dysthymic disorder (F34.1), provisional, Anxiety disorder, unspecified (F41.9), Post-traumatic stress disorder (PTSD) (F43.1)
 

Melanie has been in mental health counseling for several years through your agency and was referred to you by her last counselor who obtained a position with a local University and was leaving your company. Melanie is a 32-year-old Caucasian female who lives in a house with her boyfriend and her 9-year-old son, Gus, who suffers from ADHD, anxiety, and PTSD. Melanie is receiving psychiatric medication from your agency’s Psychiatrist, another Psychiatric practice by a Nurse Practitioner in a different city and is being treated medically by a Gastroenterologist who has also prescribed medications. Melanie is complaining of ongoing depression caused by her chronic nausea and a cyclic vomiting syndrome and does not want to leave her bed out of helplessness and hopelessness that nothing will ever change. She also reports experiencing anxiety and panic-like attacks when she is around others which causes her to socially isolate for sometimes days at a time. She is upset she cannot care for her son the way she desires and wants to continue counseling to help her feel better.
Other Contexts: Family History:
Melanie has what she states is a “complicated” relationship with her family, including her mother, whom she believes wants no involvement with her or her son, and has no contact with anyone else. Melanie states her falling out with her mother began when she was just a child. She comments that her father and her were “very close”, but his new wife makes it “challenging to communicate with him.” Melanie has lived on her own for much of her life and has not engaged in or sustained any relationship with her first three children. She adds that in each instance they were either unfairly taken away by the father or the state and that she has tried to initiate contact, but it has not been successful. Melanie continues to deflect from discussing family dynamics, causing gaps in your initial interviewing process.
 
Work History:
Melanie reports never having an “official” job but always being able to make money “somehow.” She has been on Medicaid for most of her life and continues to survive off government support and the charity of others. She tells you she has dreams of writing a book or even owning her own bakery but does not demonstrate willingness to take the steps at achieving those goals.
 
Legal History:
Melanie has incurred a criminal record for failing to pay child support several times over the past nine years and continues to receive notices and warnings to ensure she is making her payments on time.

Question: What information should you gather about Melanie's current level of functioning?
(A): How she manages her daily routine including eating and sleeping
(B): Whether she is up to date on her child support payments
(C): Her interest level in activities that bring her joy
(D): The quality of a relationship between her and her son

Correct Answer: How she manages her daily routine including eating and sleeping
Explanation: How Melanie functions daily is vital to understanding her level of current functioning both cognitively and physically. Relationship dynamics, depression, as evidenced by lack of interest in activities, and her ability to cope with external stressors such as financial obligations can all be better understood considering this first set of baseline data in answer c). Therefore, the correct answer is (C)
Competency: intake, assessment, and diagnosis