Assignment
Anjela101
CaseofMaria.rtfCASE of MARIA
Intake Date: March 21, 2021
IDENTIFYING/DEMOGRAPHIC DATA:
Maria is a 38-year-old divorced woman who works in a higher-level administrative position for a large federal agency. Maria lives in Southern California. Her ethnic background is Mexican. She describes herself as being Catholic. Maria has no children.
CHIEF COMPLAINT/PRESENTING PROBLEM:
Maria reports feeling sad ever since her divorce 2 years ago. It is against all her teachings to be divorced. She is the first divorced person in her family.
HISTORY OF PRESENT ILLNESS:
Maria describes her mood being sad especially because she can not control her eating behavior. She explains she needs help and that it’s not a matter of knowledge – “I know what to do. I just can’t do it. I cannot control my eating.” She describes a pattern where she works hard to “get on track” with her eating but finds it difficult to maintain. She is 5’4”and weighs 180 lbs. She first started eating this way in college and her weight quickly increased from 135 lbs. as a freshman to 160 lbs. by graduation. She does food shopping once week and when she goes to the grocery store, she buys junk food then sits in her car and eats it quickly, hoping the people around her do not see her. Sometimes she will move to a further end of the parking lot to hide. She is very disgusted with herself, especially since she wants to lose weight and get back to her pre-college size.
PAST PSYCHIATRIC HISTORY:
Maria reports a prior experience with counseling during college after she experienced a sexual assault. She has spent time with several different therapist for different issues but one main theme is controlling her eating habits. When she brought up her eating behaviors with two other social workers, it was recommended that she meet with a dietitian to “learn how to eat healthily.” Maria waited years to seek help again.
SUBSTANCE USE HISTORY:
Maria denies any use of elicit drugs. She does drink alcohol occasionally but rarely to excess.
PAST MEDICAL HISTORY:
Maria has all her childhood vaccinations. She has had colds periodically and the flu once. She has been treated for hypertension and high cholesterol for the last 5 years. She is coming for help now at the recommendation of her physician after a recent visit where she reported increasing problems with back and knee pain due to her excess weight.
FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC:
Maria states her parents had an average relationship. Her parents did fight periodically due to his binge drinking behavior. Maria is the oldest of 7 children. She has a close relationship with both her parents.
CURRENT FAMILY ISSUES AND DYNAMICS:
Maria is well-established in her career and has several close friends with whom she enjoys spending time. She did marry 15 years ago. She loved being married but had trouble getting pregnant so she has no children. A little over 2 years ago she discovered her husband was having an affair with another man. Maria considers herself to be understanding about this but she is sad over the loss of her previous lifestyle. She continues to maintain a strong friendship with her ex-husband.
MENTAL STATUS EXAM:
Maria presents as a casually dressed female who appears her stated age of 38. She is tense during the interview and her affect is blunted. Motor activity is appropriate. Speech is clear. There is no evidence of delusions or hallucinations. Maria’s intelligence appears to be above average. She is oriented to time, place, and person. Her mood is down. She would become teary eyed at times.
