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Case iHuman Week 14 Case Study - Billy Johnson
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Case Study Johan Bello IHuman week 14 Regis College Class: NU-664C- 02 - 20PCFA FamilyPsychiatric Ment.Hlth I Psychiatric SOAP Note Template Criteria Clinical Notes Subjective Patient name: Billy Johnson Gender: Male Age: 13 y/o Chief complaint: c/o of school refusal and difficulties with focus, attention, and concentration. HPI (History of present illness): The patient (Billy Johnson) is a 13 y/o who presented to
the clinic and was accompanied by his mother. Billy’s mother complains that the patient is refusing to attend school and has difficulties with focus, attention, and concentration. Additionally, the patient’s mother states that his teachers as well as the football coach have noted that he is highly distractible. Billy’s parents divorced recently and the patient lives in his father’s or mother’s house and this has caused the patient to be a bit frustrated and irritable. Past medical and psychiatric history: The patient has no significant past psychiatric or medical history. Allergies: NKDA Social history: Billy is a student and he lives either in his father’s or mother’s house. He has achieved all the developmental milestones that are appropriate for this age. His mother reports that he has a lot of friends but sometimes he may have disagreements with his peers since he can be annoying. The patient reports that he has no girlfriend. On the other hand, his mother reports that she smoked tobacco in her first trimester while she was pregnant with the patient but she denies the use of alcohol or illicit drugs during pregnancy. Family history: Billy’s parents are both alive but divorced recently. Objective ROS (Review of systems) General: The patient’s mother reports that the patient is having difficulties with focus, attention, and concentration as well as school refusal but the patient denies chills or fever.
MDMA (ecstasy) None 24 hours detected Methamphetamine None 3 - 5 days (Meth) detected Methaaualone None 2 weeks (Auaalude) detected Phencyclidine None 5 days (PCP) detected Morphine/Opium None 4 - 5 days detected Name Value Reference range Thyroid 3.45 0.35-4. stimulating hormone (TSH) Assessment Differential diagnoses
Non-pharmacological treatment: The nonpharmacological treatment of ADHD in pediatric patients such as Billy includes; social skills training, behavioral therapy, counseling as well as parent skills training (Shivanna & Chikkanna, 2016). As such, Billy’s nonpharmacological treatment will include; social skills, training, counseling, and behavioral therapy. For instance, social skills training will help in teaching him the appropriate or ideal social behaviors while counseling will help him to talk about the problems/issues that might be bothering him and explore negative patterns of behavior and learn how to deal with his symptoms (Shivanna & Chikkanna, 2016). On the other hand, Billy’s mother will be initiated on parenting skills training that will help her in understanding and guiding her child’s behavior (Mousavi, Pahlavanzadeh & Mehrabi, 2017). Patient education: Billy will be educated about his condition, the associated complications, and the need to comply with this treatment plan. Additionally, he will be taught about the lifestyle changes that could help in managing his condition such as the adoption of healthy lifestyle habits (Shivanna & Chikkanna, 2016). Similarly, his mother will be educated on the things that might help her to improve her child’s behavior that includes; showing him a lot of affection, encouraging him to socialize and have positive interactions, and ensuring that he has a regular schedule for bedtime and meals behavior (Mousavi, Pahlavanzadeh & Mehrabi, 2017). Referrals: The patient will be referred to a counselor and psychotherapist for the needed psychotherapy interventions. Follow-
up: The patient’s follow-up care will include; clinical appointments, home visits, and telephone conversations that will assist in monitoring his progress, hence the appropriate interventions or adjustments to his treatment plan. References
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