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.
i human 6 Billy Johnson CASE STUDY
