Case Presentation

CASE PRESENTATION

A. SUBTANCE ABUSE HISTORY

The client Tammy Harris is a Twenty-year old white female, she stared drinking at age sixteen. She stated that their had been no other drug use until the last year when she began to use Xanax. The Client has stated that the Xanax and the drinking help her sleep so she does not think of her recent divorce from a two year marriage. The drinking stared socially and the became a way to cope, from a few beers on the weekend to a twelve pack a day. The client stated that the doctor prescribed her xanax to help her relax, then she could not live without it. She began taking several a day. When the scrip ran out she visited another doctor to get another script. In the last two months she has taken ten to fifteen xanax a day along with drinking ten to twelve beers a day.

Tammy has expressed that she would like to just be happy. She was admitted into out care from County General Hospital due to a drug overdose.

B. PHYCHOLOGICAL FUNCTIONING

At the present time Tammy seems depressed and withdrawn. Her appearance is messy and seems she has not bathed in several days. She appears healthy. She is making no eye contact.

Tammy says that depression runs in her family. Her maternal grandmother was severally depressed. But there is no sexual of otherwise mental conditions. The client signifies that she has been extremely depressed since her divorce and feels no reason to live.

C. EDUCATIONAL/VOCATIONAL/FINANCIAL

Tammy stated that she finished high school early and graduated three years ago. Tammy has attended no school since high school, and says she does not plan to attend any college. Tammy has no financial resources at this time her husband was paying for everything and she is was staying with friends. She recently has been fired from her job.

D. LEGAL HISTORY

The client has stated that she has no legal problems. Tammy says that she has never been on probation or in any trouble. The only issue is her recent drug overdose.

E. SOCIAL HISTORY

Tammy states that she has lived in Alvin all her life. The Client states that her parents are in their late fifties. She states that her child was happy for the most part. Tammy states that her family is middle class. She has one older brother and a younger sister. She has no children because she can not Carrie a baby longer than eight weeks. She states that while she was married she had very few friends due to her husbands drinking and harassing people. She also states that her father also has a drinking problem. Tammy states that she has been very sad and not feeling well due to her recent divorce. She says she feels withdrawn and worthless.

F. PHYSICAL HISTORY

The client states that both her grandmothers have suffered from depression. Her maternal grandmother even attempted suicide. Tammy states that she has had three D-n C’s from miscarriages but at this time is experiencing no pain. She does not believe that she is pregnant at this time. She says that she has lost about thirty pounds and she does not feel like eating. At this time she appears to be in good health.

G. TREATMENT HISTORY

Tammy states that she has been to her regular doctor because she was nervous and anxious. She was prescribed Xanax. The client states that this is the only help she has had. She is here today because of an overdose. She states that she just wants to feel better.

H. ASSESMENT

The clients weaknesses are:

Use of prescription drugs

Use of alcohol

Depression

The clients strengths are:

She appears to be healthy and smart

She is educated

She has a strong faith background

Based on the information the client