SOCW 6530 Week 9 - Assignment 2: Application: Case Presentation

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Case M

CASE OF MARTIN

INTAKE DATE: March 2020

DEMOGRAPHIC DATA: Martin is a 38-year-old, African American, married, employed male who lives with his wife and two children in Dayton Ohio. He works as a computer technician in a car dealership. This is his first psychiatric admission.

CHIEF COMPLAINT: “My wife says she wants to leave me because she is unhappy”.

HISTORY OF PRESENT ILLNESS: Martin states he has been feeling upset and sad. His wife told him she is unhappy, and she wants to leave. Client initially went to his primary care physician who gave him Xanax for his nerves in December 2019.

He recently began to mix Xanax and alcohol because his nerves are on edge. Martin went to a therapist in January 2020 because his wife urged him to. The therapist wanted to see them together because she said this was a marital issue.

Martin explains he had a heart attack December 31, 2018. He was very stressed that New Year's Eve, trying to finish up his work and get home for their party. He had several friends over and was having a great time before his heart attack. When asked, Martin admitted to drinking a lot that night and using some drugs “recreationally”. When it was explored further Martin admitted to using marijuana and cocaine that evening.

Wife noted Martin has become more irritated over the past several months especially when she asked him to fulfill his roles around the house. She reports they have had several severe arguments about his behavior and drinking.

PAST PSYCHIATRIC/DRUG HISTORY: Martin reports that he went to a therapist as noted in History of Present Illness. He reports no other psychiatric contact prior to this time.

It should be noted that Martin had a history of substance use as follows. He first began smoking marijuana age 15. By the time he was 17 he was smoking daily. He decided to cut down and now he reports smoking marijuana on and off. At age 17½ he began to drink beer, however, since he got sick when he was 18, he no longer drinks beer. Since age 20, Martin reports he is a social drinker, drinking wine with dinner and on weekends. At the age of 26, he hurt his back. He was prescribed several different kinds of pain medication such as oxycontin, which he continues to use today occasionally. Patient reports using cocaine on weekends from 2012 until he had his heart attack. When questioned more specifically about his drinking, Martin became agitated, and stated he has several drinks to relax every day. Martin never discussed his drug use with his doctor because he reports being able to handle it and actually stops using drugs and alcohol every year for 6 weeks for religious reasons. Martin states it’s a way to give his body a rest.

FAMILY HISTORY: Patient is married for 18 years. He has a 16 and 17 year old son. Both parents are deceased. His mother died from cancer of the stomach and his father died the following year from cirrhosis of the liver. There is no psychiatric illness in the family.

MEDICAL HISTORY: Patient had a heart attack in December 2018. He is now on Blockadrin 5 mg, QD. He has hay fever. Patient smoked three packs of cigarettes per day since 17 years old. Patient also has hypercholesterolemia since January 2014. Patient reports his doctor spoke to him about his lifestyle and illnesses.

A little over two years ago Martin had a heart attack and was admitted to a local hospital on December 31, 2018 where he stayed for one week. The heart attack was considered to be stress related and Martin was urged to slow his life down.

PAST DEVELOPMENT AND SOCIAL HISTORY: Patient was born in Kansas City, Missouri and went to public schools. He graduated from high school in 2000 and tried college for several months. However, he dropped out.

He started working in the computer industry soon after he left college and has been working steadily up to this point. Patient has no legal complications.

MENTAL STATUS EXAMINATION: Upon intake the patient was casually dressed but neatly groomed male who appeared older than his stated age. He was anxious with mildly pressured speech, which was fluent, coherent and could be interrupted. There was no evidence of psychosis, paranoid ideation, delusions, or form of thought disorder. There was no looseness of association, flight of ideas, or ideas of reference. His affect was full range. He described decreased appetite and intermittent sleep problems, sometimes over sleeping.