Psychotherapy for a Patient

Psychotherapy
Your Name
Subject and Section
Professor’s name
Date of Submission
Date of Assessment: September 11, 2020
General Information:
Name: NM Age: 45 years-old Date of Birth: May 3, 1975
Occupation: Accountant Religion: Roman CatholicAddress: Houston, Texas, USA.
Presenting Problem
NM is a 45-year-old Caucasian who is married for 15 years to her 47-year-old husband. She has 2 daughters who are both in high school. NM works as an accountant. NM was referred by their company’s doctor due to some stress-related concerns.
History of Present Illness
NM reports feeling anxious and worried most of the time. She cannot pinpoint the exact reason what her worries are but stated that she worries about everything and anything. She’s been doubting herself recently and wonders if she has worth at all. She used to cry once in a while but become much worse in the past 6 months since her husband has left them. She has been crying almost every day for 2 months for various accumulated reasons. The stress that she has been feeling drains much of her energy that she would fall asleep afterwards. She often overthinks about what the future holds for her daughters and about her husband’s infidelity. Being responsible for all their households finances, she reports of binge eating on weekends. When anxiety hits her, she would often feel the tension building up on her shoulders down to her legs, her heart palpitating, and difficulty in breathing. She finds it difficult to sleep and experiences frequent wakening at night.
Past Psychiatric History
NM was last seen by her therapist 2 months ago due to her marital problems and anxiety-related issues. She is also suffering from depression since she was 43 years old.
Medical History
NM was hospitalized last July 2018 due to severe stomach pain and was diagnosed with peptic ulcer.She had also neck disc problems since May 2019. She was diagnosed with carpal tunnel syndrome last October 2019 and was treated with physical therapy.
Substance Use History
Alcohol: age of first use was 11 years old and last use reports September 3, 2020. Typically drinks about 1-2 glasses of beer.
Marijuana: experimental use as a curious teen
Cocaine and Heroin: age of first use was 22 years old and last use is reported as 2005.
Developmental History
NM had issues with speech and articulation.
Family Psychiatric History
Alcoholism runs in the maternal side and her father used to inject heroin.
Psychosocial History
NM is separated from her husband after 15 years of marriage and is currently living with their 2 daughters (CD, 14 yrs old & VE, 16 yrs old). She reports that her eldest daughter talks to her but seldom. Her youngest daughter talks to her most of the time to comfort her. She often engaged in an argument with her eldest daughter since her husband has left them. Both her daughters are in high school. Currently, she is working as an accountant in the city from Mondays to Fridays from 8 AM to 5 PM. She drops off her daughters before going to work. She used to be physically active but stopped going to the gym after finding out her husband’s infidelity. She is emotionally unstable at the present.
History of abuse/trauma
NM grew up with an alcoholic mother and a father who used to inject heroin. She was exposed at an early age to various instances of potentially being molested.
Review of Systems
GENERAL: No fever and chills. weight loss, weakness, (+) fatigue.
HEENT: No visual loss, double or blurred vision; non-icteric sclerae; pale conjunctivae; no hearing loss, sore throat, sneezing, problems of congestion. Lips are cyanotic. (+)difficulty breathing. (+) dry mouth
SKIN: No itching, rashes, wounds, or scars on the extremities, trunk, and face. Cyanotic nail beds; Capillary bed refill at 3 seconds.
CARDIOVASCULAR: (+) palpitations. Does not experience high blood pressure.
RESPIRATORY: (+) SOB when anxious
GIT: No vomiting, nausea, bloody discharges, or abdominal pain.
NEUROLOGIC: No headache, syncope, ataxia, tingling, or extremities. No changes in bladder and bowel control. Difficulty in sleeping at night. (+) dizziness
GENITOURINARY. No dyspareunia, changes in urinary frequency, dribbling, or urinary urgency.
MUSCULOSKELETAL: No muscle, back, and joint pain. (+) tensed muscles
PSYCHIATRIC: (+) hx of depression
Physical Assessment
ACTUAL PHYSICAL EXAMINATION

GENERAL SURVEY

The patient is awake, responsive, coherent, makes eye contact. No signs of respiratory distress. She is appropriately dressed. There are no odors noted. Skin is warm and dry. No rashes, petechiae or ecchymoses.
Height: 5’2”
Weight: 58 kg
BMI: 23.53 kg/m2

VITAL SIGNS

BP = 110/70 mmHg
PR = 75 bpm
RR = 16 cpm
T = 37.0° C
O2 sat = 97 %

HEENT

No facial or head deformities. Patient has icteric sclerae, pink palpebral conjunctivae.

CHEST AND LUNGS

There is a full symmetrical chest expansion. No deformities, no scars and no retractions observed. No detected masses upon palpation. Equal t...