Billy Johnson Ihuman questions
Chief Complaint – Billy Johnson is a reliable 13 year old boy who presents with his mother,
Karen Bloom, with complaints of not wanting to attend school.
HPI
History is obtained from mother and son.
Billy Johnson is a 13-year-old boy who presents with difficulty in school. Per patient mother
Billy’s teachers are concerned with his disruptive behavior, inability to follow directions,
forgetfulness, inattentiveness, and impatience. They also report that he is unorganized with his
belongings (locker and school bag) and not prepared for class. At home Billy is snapping at his
mother and procrastinating with schoolwork. Mother denies any physical emotional or sexual
trauma. At home Billy’s mother finds him to be fidgety, restless, irritable and anxious. Billy’s
football coach has also found him to be distracted during practice stating, “he needs o get his
head in the game”. Billy’s mother reports overhearing his friends refer to him as bossy or
annoying. His friends are “nice kids not top students”. Billy had a rough time with the recent
divorce but after a schedule was initiated, he is more comfortable with it. Billy does not follow a
diet but his mother limits the amount of red food dye in the home since it seems to negatively
affect his mood. Denies depression. Mother also reports Billy was hyperactive at as a toddler but
grew out of it by the age of ten. Per the patient, Billy, school makes him feel stupid and he feels
like he is always getting into trouble for things he does not do. Billy is frequently distracted and
unable to stay focused. Billy reports he has difficulty with falling asleep. Per his mother Billy
takes Melatonin at night with no positive affect. Billy reports feeling sad when he has to attend
or think about going to school. Denies feelings of anxiety. Denies decrease in appetite. Denies
feelings of fatigue or depression.
