i human 6 Billy Johnson CASE STUDY Case, Assignments of Nursing

Download i human 6 Billy Johnson CASE STUDY Case and more Assignments Nursing in PDF only on Docsity!

IHUMAN BILLY JOHNSON “A 13 YR Old boy..” With Complaints Of Not Wanting To Attend school, Difficulties With focus ,Attention And Concentration. EXPERT FEEDBACK CONTENTS; ALL QUESTIONS, OLD-CARTS for the HPI,(PIMIH,FH,SH as Needed),PHSICAL EXAM, EXAMS FEEDBACK,CASE FINDINGS,FEEDBACK, DIFFERENTIAL RANKING ,DIAGNOSIS,CASE PLAN 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. TIPI Ilistory 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 impaticnce. 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 fecling 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. Assoc Sx Assoc Sx Assoc Sx Assoc Sx Is he moving or speaking slowly or | fidgeting and restless? If so, how often? (witness) Does he feel anxious? (witness) Has he dropped many of his activities and interests? (witness) Does he have a problem with depression? (witness) Do you have a problem with _Satigueftiredness? (patient) Do you have any other ‘or concems we should discuss? (patient) Are you having any difficulty sleeping? (patient) He can definitely be fidgety or restless at times, Yes, | think | would say that. He | Does schoo! count? Just kidding. No, he's still involved with all of his usual activities, No, | wouldn't call it that. Stress. ‘about school? Yes, Billy's not one 10 put his feelings to words, so | have to mastly go on his behavior. The most he'll say is that he feels stupid and that he feels like he's always getting into trouble. He is very unhappy about school, but | wouldn't call that depression, though. No, | have a lot of energy, I'm a kid, I dont have any symptoms. | just don't want to go to school. They make me feel stupid, and I'm always getting into trouble when it's not my fault. Everyone distracts me, but I'm the one the teachers ‘say has the problem -- a “focus problem" they keep on calling it. Yeah, | quess | have a lot of energy, and maybe | have a focus problem. It's not fair that some things -- like ‘school -- are easier for my friends than forme. It's hard to fall asieep sometimes. OLD-CARTS for the HPI @ Asked X Not asked Graded Approach Onset Location Duration @ = Characteristics * — Characteristics Can you describe a typical night's sleep for him ? (witness) How would he describe his moods? (witness) Tell me how that makes you feel, (patient) He does have some problems falling asleep most school nights, but otherwise seems to sleep well, He always gets to sleep within an hour, so I'd say thal it's not too severe, | occasionally give him melatonin, but I'm not sure if it makes a difference. He eventually falls asleep. | do think he is getting enough hours of sleep. He can be irritable at times. He procrastinating more with his. homework and snapping at me when | remind him about it. Those two things ~- and a lot of the things his teachers report -- are new for him. Like teachers saying that his desk, locker, and schoolbag are messy; or that he's constantly not prepared for class and misplacing pencils and completed homework assignments, Even his football coach has been : Says Billy "needs to get his head in the About school? They make me feel ‘stupid. And kids make fun of ma because the teachers say | cant focus. | just don't like it. I'm OK and happy at football practice and when ‘school's out. That's it. Information PMH, FH, SH as Needed @ Asked X Not asked Graded Approach Question PMH PMH Is he taking any medications? (witness) Has he had any significant traumatic injuries or accidents? (witness) Can you tell me about any current of past medical problems he has: had? (witness) Is he taking any over-the-counter or herbal medications? (witness) Were there any complications with his birth? (witness) Response Nota one. Thank goodness, no. Billy's real active in sports and has never had & head injury or broken bone. Nothing! Couldn't be healthier. It's just his behavior. You know, his teachers have observed ‘some of these school issues back as far as first grade, but Billy has always managed to do fairly well academically until recently. As a younger boy, Billy was hyperactive both at home and at school, His father never wanted Billy to be evaluated: He always said, “Boys will be boys.” Billy grew aut of that ‘hyperactivity for the most part by the time he was ten. He still occasionally blurts things out or is restless. | occasionally give Billy melatonin at nighttime, but I'm not sure if it makes a difference. No. It was a very easy, normal Pregnancy and he was born by vaginal delivery at full term. He was healthy as can be...3000 grams on the nose! | do have to tell you, though, that | smoked during the first trimester, One pack a day up until 12 weeks' gestation -- that's when | found out | was pregnant. I've only had alcohol twice in my lite and that was way before | ever became pregnant, and I've never done any drugs in my life. Phy gone any Uruyes mi my me, Nothing out of the ordinary. And since you're going to ask; There What childhood ilinesses has he was none of the physical or sexual had? (witness) abuse or emotional trauma that you see on TV. Up until the divorce, our family life was pretty uneventful. Billy's always been a healthy, How is his overall health? (witness) pve eect lyeh hr an time. ‘Oh, my goodness, no, He's a kid at heart, not a teenager. But he does ‘seem to be physically developing Quite normally in that regard. ‘What do you want to know? My mom and dad got divorced a year ago. It's OK now, or al least better. | How is your family and family life? —_ like staying at my mom's best - (patient) ‘she has the X-Box and the games. I'm OK with staying at my dad's one weekend a month. | guess they're both happier now. Billy kes team sports: basketball and football. He's on the football Tell me about daily exercise or won't follow directions, Is he sexually active? (witness) Do you now or have you ever smoked or chewed tobacco? Nope, My mom would kill me! (patient) | | Why are you asking me this? No, eee obviously I've never done any . ae | drugs. I'm not a bad kid, Do you drink alcohol? It so, what do | you drink and how per its Aa lei ama day? (patient) | Does he use any recreational No, not Billy, And it's not a big drugs? If so, what? (witness) problem at his middie schoo! -- yet. I make sure thathe has a balanced Can you tell me his diet? diet. One thing | can say for sure is What does he normally eat? et bee bes ees waned yes} aa try to make sure that there's none San) im the food that | have some contro! ot. Exams Feedback ®@ Performed Correctly + assess cranial nerves Cranial-nerve impairment may be seen in a broad variety conditions, © Assessment may reveal comorbid sensory defects (e.g., visual, auditory, olfactory). © Various sensory impairments may contribute to learning challenges. * assess gait & stance Dyskinesia may invoive distortion of voluntary movement and/or uncontrolled involuntary movement. It is important to evaluate if Billy has dyskinesia versus general fidgeting. + auscultate abdomen © You performed the simulation correctly. + blood pressure e You documented pulse pressure, systolic/diastolic, and assessment correctly. © You performed the simulation correctly. * examine pupils © You performed the simulation correctly. © You documented left pupil and right pupil correctly. = inspect skin overall ‘Skin can often reflect internal hormonal abnormalities. Therefore, it is important to do a general evaluation on this organ. + Inspect/paipate head Observe for any distinguishing facial features or dysmorphias. Certain genetic and hereditary syndromes are known to be risk factors for behavioral abnormalities: » Low-set ears and wide-set eyes: Fragile X; Williams syndrome © Flattened philtrum: Fetal alcohol syndrome © Microcephaly: Maternal smoking during pregnancy + look far involuntary movements Dyskinesia may involve distortion of voluntary movement and/or uncontrolled involuntary movement. It is important to evaluate if Billy has dyskinesia versus general fidgeting. * mini-mental state exam (MMSE) Concentration problems are relatively nonspecific and can frequently overlap with many different disorders. An accurate assessment will help differentiate among the disorders, * palpate neck Thyroid should be assessed for size, symmetry, and consistency, © Hyperthyroidism and hypothyroidism should be considered as a potential medical explanation for problems with concentration and learning. © if hypothyroidism is suspected, the physical exam may show: = Bradycardia, dry skin; coarse, dry hair, fatigue, coldness » Hyporefiexia with delayed relaxation phase » Gl symptoms of constipation, weight gain, hypersomnia = Difficulty concentrating and decreased memory © If hyperthyroidism is suspected, the physical exam may show; = Tachycardia, * Hyperrefiexia with extremity tremor = Gl symptoms of diarrhea, weight loss, insomnia = Difficulty concentrating and remembering + retiexes - deep tendon DTRs should be assessed as an indicator of other central or peripheral nervous system deficits. © You performed the simulation correctly, « test hearing Hearing should be checked in all children with a change in school performance especially when there appears to be a concer for inattentiveness as diminished hearing could appear as inattentiveness. « test visual acuity Visual abnormaiities or the need for acuity correction should be evaluated in ali children with a sudden change in school performance. Your Differential Ranking @ Correct € Incorrect Differential Your Your Your Diagnosis Lead Graded Alt Graded MNM Graded attention deficit hyperactivity disorder ® ° ie) Oo (ADD/ADHD) depressive disorder e a e generalized anxiety disorder is] hyperthyroidism substance use disorder O |e] O 6 ®2\9 © 0 1] | Feedback Diagnosis Diagnosis: Attention-deficit / hyperactivity disorder; predominately inattentive presentation Discussion: Billy has met the following criteria for this disorder: Careless mistakes in schoolwork Difficulty sustaining attention Failing to finish schoolwork Poor time management Forgetfulness with regard to daily activities Loss of equipment necessary for tasks or activities Demonstration of these symptoms both at home and at school Case Plan General considerations: + Discuss stimulant medication as first-line treatment. * Consider pretreatment ECG if there is a personal history of heart disease, or a family history of unexplained syncope or ‘sudden cardiac death. + Utilize Conners rating scales, Child Behaviors Check List (CBCL), and Vanderbilt ADHD scales at baseline and for Jongitudinal monitoring of reatment response al school. The Conner’s forms and Vanderbilt forms are given to parents and teachers who assess the patient on his/her attention, focus, concentration, impulsivity, and general behavior during class. These forms are given to both aid in the diagnosis, as well as, to monitor treatment response. The CBCL is a screening too! given to parents that assess problem behaviors of the child. This check list helps to identify what patterns of behaviors are present. + Monitor weight, blood pressure, and pulse over time. * Consider a nonstimulant trial if the patient fails to tolerate or benefit trom a stimulant trial; or, if the parent refuses a ‘stimulant trial for his/her child. + Suggest parenting training and behavioral-modification plans for augmentation of the medication strategy, Plan for Billy: + Provide Vanderbilt ADHD scales for parents and teachers to complete prior to starting Billy on any medication, + Review results of the Vanderbilt ADHD scales and initiate a stimulant trial if the findings are consistent with ADHD. + Monitor Billy's blood pressure, weight, and pulse at every visit. + Send parents and teachers Vanderbilt ADHD forms prior to each of Billy's visits for their assessment of his progress while ‘on the stimulant medication,