Name: Michelle Joy Williams
Therapist Name: Alexandra Wong, Ph.D,
Family Members Present: None
Emergency Contact: Melissa Lee Williams
Date of Service: 5-29-2016
Type of Service: Intake (900801)
Service Setting: North Eastern Emergency Room.
Patient report of recent symptoms and behaviors:
Michelle was admitted to the North Eastern Emergency room after a counselor at Canton Jr. High reported that Michelle fell down into the fetal position outside of the girls bathroom after having visual and auditory hallucinations. The client continues to refuse to remove or respond.
Upon arrival the patient was in the fetal position still unresponsive lying upon the hospital bed. There were no verbal noises and the patient seemed to be almost sleeping or catatonic.
History of the presenting difficulties:
Michelle lived with her grandmother, Marjory Alice Williams, from the time she was five years old until last summer, 5-29-2015, when she passed away. The social worker reported that the adjustment seemed to go well at first, Michelle was maintaining a 3.25 GPA, made friends, participated in a school’s art club, and got along well with her peers and adults. By January, Michelle’s grades began to drop, and she slowly started to become selectivity mute. The social worker contacted mom with weekly updates, but rarely received communication back. Melissa began to receive weekly services for 40 minutes per week and an initial Evaluation was opened February, 2016.
Significant life history and background information:
The patient is the only child born to a single mother, Melissa Lee William. An agreement was made between Melissa and her mother, Marjory Alice Williams, that Michelle should live with her grandmother when Michelle was five years old due to the fact that her grandmother was retired and could care for Melissa’s needs at all hours of the day while her mother worked. Her mother came to visit her often and there seemed to be no significant relationship strain. Michelle was brought up in a middle-class environment and attended Lakeview Elementary from the time she was five until eleven years old where she graduated and began to attend Keller Jr. High. As stated above, the adjustment seemed to go well at first. Michelle was maintaining a 3.25 GPA, made friends, participated in a school’s art club, and got along well with her peers and adults. By January, Michelle’s grades began to drop, and she slowly started to become selectivity mute. The social worker contacted mom with weekly updates, but rarely received communication back. Melissa began to receive weekly services for 40 minutes per week and an initial Evaluation was opened February, 2016. Concerns at the time were distractibility, signs of depression, moments of confusion, fatigue, withdrawal from people, social discomfort, a decline in motivation and self care as well as hearing voices.
Significant Medial History:
According to the school nurse, Michelle passed her vision and hearing test on 10-23-2015. School physicals indicated that all of her records are up-to-date and that all physical health is within normal limits. No concerns at this time.
The patient’s clinical presentation suggests a possible diagnosis of schizophrenia due to experiencing affect flattening, hallucinations, and catatonic behavior. The onset of the dysfunction is significantly impairing her ability to function physically and emotionally.
Recommendation and Preliminary Treatment Plan:
Immediate admittance to the North Eastern Behavioral Health inpatient services in order to monitor symptoms as well as conduct further diagnostics tests: a Complete Blood Count, a drug and alcohol screening, and further psychological evaluation based upon further observations. 1 mg Xanax to promote relaxation and sleep.