i human 6 Billy Johnson CASE STUDY, Exams of Nursing

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i human 6 Billy Johnson

CASE STUDY

PSY MISC i-human 6

Billy Johnson

Billy Johnson 13 yo “I hate school” With his mother Observations ● ● Fidgeting Warm, dry skin Last Visit One year ago, billy was seen for his well check. He was noted to be a little hyperactive at times; his parents had recently divorced and he was a little irritable and frustrated with having to go between his mother’s and father’s house. Had difficulty following his coach’s directions. Father has a history of cocaine abuse. Differential Diagnosis 1 2

. ADHD - Lead . Hyperthyroidism - MnM a. TSH 3 4 . Generalized anxiety disorder . Substance use disorder - MnM a. Drug toxicology, urine

5. Depressive disorder - MnM Plan ● Discuss medication as first line treatment ● Consider pretreatment ECG if there is a personal history of heart disease, or a FH of unexplained syncope or sudden cardiac death Utilize Conners ratings scales, child behaviour checklist (CBCL), and Vanderbilt ADHD scales at baseline for longitudinal monitoring of treatment response at school.

● Monitor weight, blood pressure, and pulse over time

Missed ● Patient ○ Do you have a problem with fatigue/tiredness? ■ No i have a lot of energy i am a kid ● WItness ○ Does he have a problem with depression? ■ No i wouldn't call it that -- stressed, yes. He is not one to put his feelings into words, so I have to mostly go on his behaviors. He says he feels stupid and that he feels like hes always getting into trouble. He is very unhappy about school but i wouldn't call it depression ○ ○ Has he dropped many of his activities and interests? ■ no Is his anxiety better or worse at any time of the day, week, or year? ■ (^) He says he feels better staying home from school and he does sleep better on the weekends. ○ ○ Can you describe a typical night's sleep for him? ■ (^) He always gets to sleep within an hour or so, id say that its not too severe. Can you tel me about any current or past medical problems he has had? ■ Nothing, couldn't be healthier but his teachers have always reportedly observed some of these school issues back as far as the first grade. He was really hyper as a kid but his dad wou;dnt have him evaluated. He grew out of the hyperactive stage by age 10, but he still blurts things out or is restless. ○ ○ Were there any complications in his birth? ■ (^) No, very easy and normal. Full term vaginal delivery. Smoked until 2nd trimester them quit Is he sexually active? ■ (^) No but he does seem to be developing quite normally in that regard

○ Tell me about daily exercises or sports that he plays. ■ He likes team sports. He is on the football team and his coach is complaining that he won't follow directions ○ Physical Exam ● ● ● ● Inspect skin overall ○ Skin is warm, dry and no lesions are seen Visual acuity ○ 20/20 R and L eyes Test hearing ○ No hearing deficits normal weber and rinne tests Inspect and palpate head ○ Non-tender, no rashes, scars, edema, masses, lumps, evi or other lesions ● Inspect and palpate neck ○ ○ ○ No visible scars on neck, no deformities or other lesions, trachea is midbline and freely mobile No asymmetry or accessory respiratory muscle use with quiet breathing Thyroid normal in size and symmetrical, no palpable masses or nodules, no thyroid thrills or bruits ● ● ● Neurological: gait and stance ○ Normal gait and posture, fidgeting throughout exam Reflex tests - deep tendon ○ MMSE ○ 2+ throughout Fair eye contact, irritabl affect that brightens as session progresses ○ ○ Occasional distractibility, not hearing the interviewers questions fully the first time or looking away from/past the interviewer Some errors made: serial sevens was ⅗ and WORLD backwards was DRLOW; immediate register and recall intact