SG HAS AN 8-MONTH-OLD BABY GIRL. THE PATIENT WENT TO SEE THE FATHER OF THE BABY RECENTLY AND HE BEAT HER UP. MOTHER REPORTS SG WAS GOING OUT WITH DIFFERENT MEN AND THEN GOT PREGNANT. ADDITIONALLY, SG HAD BREAST IMPLANTS PRIOR TO GETTING PREGNANT. ONCE SHE WAS PREGNENT THEY CAUSED PROBLEMS AND THEY HAD TO BE REMOVE

NRNP 6645 Psychotherapy with Multiple Modalities Essay Paper

SUBJECTIVE DATA

Chief Complaint: “Referred for treatment due to impulsivity.”

History of Presented Illness

The client SG is a 19-year-old-female. The client is presented to the clinic for being impulsive. She uses her mother’s credit card to order gifts and other items for her friends. Consequently, the mother cut SG off from using the credit card. The mother has referred her for treatment due to impulsivity, which started when she was a young child. The mother reported that SG has an 8-month-old daughter. She was recently beaten up by the father to her daughter upon visiting him. The mother added that SG was going out with different men before becoming pregnant. Her mother also revealed that the client had once tried to jump out of a moving car. SG’s mother and mother’s boyfriend have been taking care of her baby.  NRNP 6645 Psychotherapy with Multiple Modalities Essay Paper

Medications: Psychotropic and she was noncompliant

Psychotherapy or previous psychiatric diagnosis: No history of psychiatric diagnosis or psychotherapy.

Social History: The client lives with her mother, her biological siblings, her step father, three step siblings, and her 8-month-old baby girl. Her biological father died when SG was 13.

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Reproductive history: Before getting pregnant, the client had breast implants. She removed them during her pregnancy since they were causing some health issues. She has a 8-month-old daughter.

ROS

General: She denies weakness or fatigue.

Skin: She denies skin rashes.

HEENT: The client denies head injuries. She denies blurred vision. She denies hearing difficulty. She denies nasal congestion. She denies difficulty swallowing.

Respiratory: Denies wheezing sound.

Cardiovascular: Denies shortness of breath.

Gastrointestinal: Denies constipations.

Genitourinary: Denies blood in the urine.

Peripheral Vascular: Denies changes in temperature.

Musculoskeletal: Denies back pain.

Neurologic: Denies numbness.

Hematologic: Denies bleeding.

Endocrine: Denies increased hunger or thirst.

Psychiatric: Denies suicidal ideations. Reports impulsivity.

OBJECTIVE DATA

Physical exam

General: The client is a 19yo female. The client seems to be well-developed, nourished, and healthy. She is appropriately dressed for today’s weather. She seems to be easily distracted and her mother answers most interview questions on her behalf. She seem to be in mild distress. NRNP 6645 Psychotherapy with Multiple Modalities Essay Paper

Vitals: Temp-97.4*F, B/P-128/80, HR-96, RR-19, Pulse Ox-99%, Weight – 178 lbs, Height – 5′ 8″ and BMI score of 27.1

Skin: No rashes or swellings.

Head: Long, brown, and evenly distributed hair. Both eyes are sensitive to light. No drainage noted on both ears. No external lesions on her nose. No bleeding gums or mouth ulcers.

Neck: Trachea is midline

Breasts: No masses on both breasts.

Respiratory: Lungs clear to auscultation

Cardiovascular: Regular heart rhythm.

Gastrointestinal: Non-tender abdomen.

Genitourinary: No blood seen in the urine.

Musculoskeletal: Normal motor strength                                                                                                                                                                                                                                                                                                                                                Neurological: Symmetric