Case Study Mr. Williams
Mr. Williams is a 42 year old male who presented to the the ED with severe anxiety. He denies feelings of depression, however reports frequent crying spells over the course of the past few weeks. At the time of the assessment Mr. Williams is calm and cooperative. Mr. Williams reports tonight while at work he became tearful, felt like his face was heating up, and "butterflies in his stomach." He expressed the noise from the machine had some effect on his mood. Mr. Williams reports over the past few months he has been experiencing increase anxiety and does not know why. He states, "My life is going well from what I have been through in my past." Mr. Williams reports working and spending time with his family as his the most important things to him.
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He reports a history of substance abuse and trauma from finding his brother dead behind his home January 4, 2002 at 10:30am.
Mr. Williams reports going to counseling after the experiences, however discontinued outpatient services a year later. Mr. Williams reports loss of is father in 1985 on December 25 and Sister in 2006 around the same time. He expressed these losses as difficult for him. Mr. Williams states,"I have no friends anymore, I spend all my time with my family and out of my family, dead or live, I'm the most emotional one." He becomes tearful while explaining his relationships among his family member. He denies suicidal ideation, homicidal ideation, and symptoms of psychosis. Mr. Williams denies any mental health history or hospitalization for the same. He states, "Life is great." During the assessment Mr. Williams does appear guarded about reporting in detail history of drug use and stressors that may be contributing due to poor health. He reports standing up at work for 5 days a week for 12 hours and having continuous pain in both his knee. He reports no prescribed
medications.
According to Mr. Williams most recent UDS was negative for all tested drugs. HE reports a history of Heroin use, cocaine, and marijuana. He reports being 8 years clean from Heroin and other drug use. Mr. Williams expressed he has came a long way and made his family as his primary focus.
This information was reviewed with Dr. Marcus Gentry and Howard McQuirter, LCSW. They both share the disposition that the patient should be discharged pending his agreeing to follow up with outpatient services. Patient has agreed to follow up with outpatient services as recommended. The patient's family member has been contacted and made aware of the plans concerning the patient. Patient contracted for safety, was given outpatient referral information, and completed a crisis plan.
Jamaral Rease, LCSWA
He reports a history of substance abuse and trauma from finding his brother dead behind his home January 4, 2002 at 10:30am.
Mr. Williams reports going to counseling after the experiences, however discontinued outpatient services a year later. Mr. Williams reports loss of is father in 1985 on December 25 and Sister in 2006 around the same time. He expressed these losses as difficult for him. Mr. Williams states,"I have no friends anymore, I spend all my time with my family and out of my family, dead or live, I'm the most emotional one." He becomes tearful while explaining his relationships among his family member. He denies suicidal ideation, homicidal ideation, and symptoms of psychosis. Mr. Williams denies any mental health history or hospitalization for the same. He states, "Life is great." During the assessment Mr. Williams does appear guarded about reporting in detail history of drug use and stressors that may be contributing due to poor health. He reports standing up at work for 5 days a week for 12 hours and having continuous pain in both his knee. He reports no prescribed
medications.
According to Mr. Williams most recent UDS was negative for all tested drugs. HE reports a history of Heroin use, cocaine, and marijuana. He reports being 8 years clean from Heroin and other drug use. Mr. Williams expressed he has came a long way and made his family as his primary focus.
This information was reviewed with Dr. Marcus Gentry and Howard McQuirter, LCSW. They both share the disposition that the patient should be discharged pending his agreeing to follow up with outpatient services. Patient has agreed to follow up with outpatient services as recommended. The patient's family member has been contacted and made aware of the plans concerning the patient. Patient contracted for safety, was given outpatient referral information, and completed a crisis plan.
Jamaral Rease, LCSWA