Background: the patient is a 40-year-old woman with a history of gastric bypass surgery (June 2013) and multiple chronic health issues, including colitis (possible Crohn’s disease) and reactive hypoglycemia. She has a complicated eating history, managing dietary restrictions due to her GI condition and post-surgery digestive challenges. She is currently undergoing infusions for IBD (inflammatory bowel disease) every four weeks and has struggled with emotional distress stemming from family dynamics, financial concerns, and self-worth issues.

Presenting Issues:

• Emotional: the patient experiences fluctuating moods tied to family stress, self-esteem challenges, and anxiety. She reported difficulties managing her emotional responses to past family events, especially related to her ex-husband and her son, Carlos’s, birthday.

• Physical: the patient’s eating challenges due to her gastrointestinal condition, coupled with reactive hypoglycemia and difficulty tolerating fresh vegetables, complicate her nutritional intake. She also struggles with anxiety, which affects her ability to engage socially and emotionally.

Subjective Symptoms

1. Emotional and Psychological State: the patient reported feeling generally positive but experienced frustration over her ex-husband’s interference in her son’s birthday plans. This added to her emotional distress. However, she acknowledged the progress she has made in setting healthy boundaries, which has improved her self-esteem and emotional regulation. Additionally, the patient mentioned using mindfulness-based techniques such as breathing exercises and anchoring exercises, which have reduced her anxiety levels significantly.

2. Physical Health and GI Symptoms: the patient’s post-bariatric surgery history includes difficulty tolerating certain foods, specifically fresh vegetables, and experiencing episodes of reactive hypoglycemia, particularly after exercise. She has managed to stabilize her weight at 178 lbs, down from 195 lbs, and continues to work on improving her dietary intake, particularly focusing on adding fruits and vegetables.

3. Family Dynamics: the patient reported ongoing frustration with her ex-husband's behavior, particularly regarding how it impacts her son’s emotional well-being. Despite these challenges, she expressed a sense of empowerment through her new ability to set boundaries with him.

4. Therapy Progress: the patient has been working with a trauma therapist, which has helped her make significant strides in reframing childhood memories, especially those tied to feelings of inferiority and self-worth. She has also found relief from anxiety and negative emotional states through the use of Timeline Therapy, mindfulness exercises, and physical activity (running).

Objective Findings

• Mental Health: During sessions, the patient was well-groomed, engaged, and demonstrated insight into her situation. She exhibited a generally positive mood with occasional frustration when discussing past family conflicts. She appeared calm and collected, showing no signs of acute anxiety or distress during sessions.

• Physical Health: the patient’s weight is stable at 178 lbs, with a BMI of 29.6. Her physical activity includes Pilates five days a week or walking, and she drinks approximately 120 oz of water daily. Her dietary intake consists of protein-rich meals, occasional protein shakes, and small amounts of fruits and vegetables. She avoids alcohol and uses medical marijuana for GI symptom management. She remains on several medications for her GI condition and mental health, including Zoloft and Protonix.

• GI and Nutritional Status: the patient is slowly incorporating more food variety, such as sweet potatoes, carrots, and certain fruits, though she struggles with fresh vegetables. Her GI doctor has not yet ordered labs, but she is planning to consult a bariatric surgeon and her primary care physician (PCP) regarding her nutritional status and hypoglycemia.

Assessment and Progress

• Emotional Well-Being: the patient has made significant progress in managing her emotional state. She is learning how to use mindfulness techniques (e.g., anchoring and diaphragmatic breathing) to manage anxiety. Timeline Therapy has been effective in helping her release feelings of guilt and anger, particularly tied to childhood memories and past family trauma.

• Behavioral Changes: the patient has improved in setting boundaries with her ex-husband, which has resulted in better emotional regulation and self-esteem. She is also gaining insight into her patterns of financial scarcity and is working to reframe these beliefs using therapeutic techniques.

• Physical Health: the patient is slowly improving her nutritional intake and has stabilized her weight. However, her reactive hypoglycemia episodes and difficulty tolerating fresh vegetables remain challenges. She continues to work with her healthcare providers to address these issues, including her GI doctor and bariatric surgeon.

Plan of Action

1. Short-Term Goals:

• Social Engagement: Encourage the patient to engage in social activities and establish a support network while maintaining boundaries with her ex-husband.

• Dietary Experimentation: Continue to gradually introduce fruits and vegetables, starting with canned options, and monitor for tolerability. Track food intake in a journal to assess nutritional patterns.

2. Medium-Term Goals:

• Carlos’s Graduation: Support the patient in her efforts to assist her son Carlos in his upcoming high school graduation. This goal will provide her with a sense of purpose and accomplishment, especially in navigating family dynamics.

• Physical Health: Encourage continued physical activity (running, Pilates), focusing on building strength and improving overall well-being.

3. Long-Term Goals:

• Relocation to Austin, TX: Assist the patient in her plans to move to Austin next year, helping her to develop a plan for relocating while managing her emotional and physical health needs.

• Therapeutic Work: Continue to support the patient’s emotional growth, particularly around releasing feelings of shame and guilt through Timeline Therapy and reinforcing her progress with boundary-setting and reframing beliefs.

4. Medical and Nutritional Support:

• Consultations: the patient will follow up with her bariatric surgeon and PCP for lab work and further guidance on managing reactive hypoglycemia and improving her nutritional intake.

• Mindfulness and Coping Skills: Continue practicing mindfulness exercises, including diaphragmatic breathing and anchoring techniques. Incorporate more advanced techniques like progressive muscle relaxation and visualization to further support emotional regulation.

Follow-Up

• Next Session: 11/11/2024 at 1:30 PM EST, focusing on further refining the patient’s emotional coping skills and progressing with her physical health goals.

• Ongoing Support: Regular check-ins with the patient’s trauma therapist and continued development of her coping strategies to maintain emotional balance in the face of family stress and physical challenges.

Summary: the patient has made notable progress in both her emotional and physical health. Through a combination of mindfulness techniques, therapeutic interventions (including Timeline Therapy), and lifestyle changes, she is better managing her anxiety, improving her self-esteem, and taking charge of her physical well-being despite ongoing health challenges. Her goals moving forward include fostering a balanced lifestyle that addresses her emotional, physical, and familial needs, with a particular focus on her upcoming move to Austin and her son’s graduation.