Medical Case Study Martha

Drug History and Current Pattern of Use: Martha has a history of alcohol use disorder. Client has stated she has eight to twelve drinks a day, never having fewer than five drinks.
Substance Abuse Treatment History: The client has no history of substance abuse treatment.
Medical History and Current Status: Doctors have reported Martha has impacted liver function and is developing cirrhosis of the liver. Aside from substance-related health impairments Martha is in good health and appears to have no other physical health issues or ailments.
Family History and Current Relationships: Martha was born into a two-parent household located in an affluent New York suburb. Her father was a successful academic and university administrator. Her biological
There is no clinical evidence of psychomotor disturbance. The client maintained adequate eye contact. The client has been prescribed Benzodiazepines to combat her symptoms of withdrawal. Although there was some slowed speech and the occasional slurred word her speech was coherent, spontaneous and appropriate with normal rate, volume and rhythm. She described her mood as “blue.” Objectively her mood was a combination of sad, ashamed and distracted. Her affect is full range, appropriate, with spontaneous emotional reactivity. There were no clinical features of psychotic illness. Her behavior is appropriate for a person who is in a hospital being treated for acute alcohol poisoning and withdrawal. Her memory for recent and remote events is intact, yet recent memories are slightly “hazy” at times. She is well oriented to place, time and person. Her concentration and attention were both adequate, although at times she did trail off and lose track during our conversation. She was able to add and subtract figures without difficulty. Her level of intelligence and fund of general knowledge is within the normal range. Her level of personal hygiene is adequate. She was able to communicate clearly and was able to achieve goal directed ideas without difficulty. She denied any current suicidal or homicidal ideation. Client disclosed ideations of “It all being just too much,” frustration with treatment and
It is my professional opinion that she should remain on site for at least eight days. During this time I will continue to build a report with Martha by talking with her about her life. This will enable me to gain insight into what her life has been like. During our sessions I will utilize basic counseling skills by listening attentively, using reflective statements and expressing empathy when appropriate. Additionally I will identify Martha’s strengths as well as sources of support and help Martha relate her experience to the here and now. It is my hope that this client-centered approach will help foster trust in our relationship. If the client is willing I would like for her to begin attending group meetings tomorrow. If she is not open to attending the Alcoholics Anonymous (AA) meetings the organization brings to the facility I will see if she is open to attending our in house group psychoeducational classes. These would enable her to learn about substance use, its consequences, symptoms of withdrawal, coping strategies and relapse prevention. My first impression about Martha is that she values her autonomy so in individual treatment, it will be important to work collaboratively with her. Group will provide her with a base of information and I will focus on evoking change through motivational interviewing. Although it appears Martha has attempted to reduce her drinking at times it does not