i human 6 Billy Johnson CASE STUDY PSY MISC i-human 6 Billy Johnson, 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. History

1. How can I help you today? a. My mom made me come here. I don't have any problems -- I'm fine, i'm normal, I just don't want to go to school, okay??

1. What has been happening since your last visit? a. This is my first visit??? HOW I HAVE RECORDS FROM ONE YEAR AGO 3. Mother: How can I help him today? a. His grades are dropping and he is refusing to go to school. He’s always had difficulties at school but things have been getting worse over the past year. And theres so much more going on 4. Mother: Any other symptoms or concerns we should discuss? a. Yes - both as school and home. His teachers all say he is very disrupt and has problems following directions, remembering things, and waiting his turn. His teachers report that he spends more time paying attention to his neighbors or looking out the window than focusing on class instructions and discussion. They

lot of energy, and maybe i have a focus problem =. It's not fair that some things like school are easier for my friends than for me.

13. Tell me how that makes you feel. a. They make me feel stupid. And kids make fun of me because the teachers say I can't focus. I just don't like it. I'm okay and happy at football practice and when school’s out. That’s it.

1. What is your name?
2. Where are you?
3. What time is it?
4. What happened?
5. How does this affect your life? a. Not really
6. When did your trouble concentrating or making decisions start? a. I don't know i don't know if I really have a problem. They say i'm not paying enough attention
7. Mother: when did his trouble concentrating or making decisions start.
8. Tell me about your family and friends. Has anything changed? a. Just the divorce a year ago
9. Tell me about your boyfriends and girlfriends. a. I have a lot of friends
10. Do you or any family members have problems with bullying? a. Nope
11. Mother: does he have problems with bullying? a. Not that i know of
12. How would you describe your moods? a. I get frustrated if that's what you mean
13. Do you feel full of energy? a. I guess i have a lot of energy Hint 1: 5/ ● 14 more in associated symptoms ● 2 more in HPI

● 6 more in PMH ● 9 more in SH ● 1 more in FH ● 1 more in etiology

1. Mother: are his immunizations up to date?
2. Are you taking any prescription medications? a. No, not taking anything
3. Are there any diseases that run in your family? a. No
4. Health of grandparents, parents a. Ask my mom 31. Mother: Health of his grandparents, parents, siblings? a. His dad is 43 and pretty healthy. He did have school problems too, though, poor grades and disciplinary problems; he dropped out of high school and sometime later earned his GED. He also had a problem later with cocaine abuse. I am 38 and haven't had any problems. I did have a concentration problem when I was a kid and they gave me medication that my parents thought worked well. And then when i was attending community college i was given a stimulant. I guess they thought i had some sort of learning problem. 32. Do you drink alcohol? a. No 33. Do you use any recreational drugs? a. No, I've never done drugs. I'm not a bad kid. 34. Do you smoke? a. No, my mom would kill me.
5. Tell me about daily exercises or sports that you plat. a. I love sports -- basketball and football. 36. Mother: does he drink alcohol? a. No 37. Mother: does he use drugs?

● 2 more in HPI ● 5 more in PMH ● 4 more in SH ● 1 more in etiology

1. Mother: has he had any seizures? a. no 52. Mother: had he had any significant traumatic injuries or accidents? a. No Never had a head injury or broken bone,
2. Are there any diseases that run in his family? a. No
3. Mother: Is it difficult to sleep? a. Sometimes
4. Do you take anything to help you sleep? a. Ask my mom
5. What do you do when you can't fall asleep? a. Nothing
6. Mother: does he take anything when he can't fall asleep? a. i occasionally give him melatonin at night, but i'm not sure if it makes a difference
7. On average, how many hours do you sleep a night? a. 6 - 8 59. Have you been feeling sad, depressed, or hopeless? a. School makes me sad. Every day. I ont want to go anymore.
8. Negative thoughts again, whoops a. Don't have that problem
9. Have you lost interest in things that used to give you pleasure? a. No
10. Have you dropped many of your activities and interests? a. No 63. Do you feel anxious? a. I'm not sure what that means. I just don't want to go to school

1. Are you moving slowly or fidgeting and restless? a. I feel restless lots of times
2. Have you had any thoughts of hurting or killing yourself? a. No, of course not. 66. Mother: is he moving or speaking slowly or fidgety and restless? a. He can definitely be fidgety or restless at times 67. Mother: does he feel anxious? a. Yes, I think I would say that. He seems to have some anxiety related to school. 68. Mother: how would he describe his moods? a. He can be irritable at times. He says little things make him frustrated. His football coach even says Billy needs to “get his head in the game” and is always distracted and having difficulty following directions.
3. Is he in good spirits most of the time? a. Most of the time he seems ok.
4. Has he recently had any mood or personality changes? a. I wouldn't exactly call it a personality change, but i can say that he is having more and more trouble in school and now he refuses to go 71. Mother: tell me about his boyfriends and girlfriends. a. He's got plenty of friends, nice kids, not top students and i think he even had a girlfriend last year. But sometimes he does have problems with his friends -- i've heard that kids think billy can be bossy or annoying 72. Mother: tell me about his family and friends? Has anything changed? a. His dad and I divorced a year ago. He had a hard time during the first couple of months having to go back and forth. He was pretty irritable and refused to do his chores. But he’s doing better now and seems to be happy spending one weekend a month with his dad.

a. Divorce a year ago, better now. I like staying with my moms the best. I'm okay with staying at my dad's house one weekend a month. I guess they're both happier now.

1. Have you lost interest in or avoided social activities?
2. DO you blame yourself for everything wrong? a. No but my teachers sure do
3. Have yo had to deal with discrimination? a. No
4. Tell me how that makes you feel a. Blah
5. Idk
6. How does this affect your life? a. I don't want to go to school
7. Mother: How is family life? a. Things are fine
8. How often do you get the emotional support you need? a. Why do you need to know that?
9. Any recurring or intrusive thoughts or behaviors? a. No 96. Mother: Is he eating too little or too much? a. No
10. Mother: has he lost interest in things that used to give him pleasure? a. No
11. Does he feel like he is being punished? a. More like singled out
12. What time does he go to sleep? a. Around 9 or 10 100. Mother: how is his overall health? a. Good

Differential Diagnosis

1. ADHD - Lead
2. Hyperthyroidism - MnM a. TSH
3. Generalized anxiety disorder
4. 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 ● Consider a non-stimulant trial if the patient fails to tolerate or benefit from a stimulant trial;, or, if the parent refuses a stimulant for his/her child. ● Suggest parenting training and behavior modification-plans for augmentation of the medication therapy 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

○ 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 ○ 2+ throughout ● MMSE ○ 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 ● Cranial nerves ○ I-IX intact ● Involuntary movements ○ Fidgeting throughout exam, no other involuntary movements noted Assessment ● MSAP: impaired attention, focus, and concentration ● Related

○ Multiple behavioral concerns ○ School refusal ○ Anxiety ○ Cognitive-testng eros ○ Initial insomnia ○ Parents divorced within the last year ○ FHx of mother being prescribed a stimulant as a young child and adult ○ Fidgeting ● Unknown ○ Maternal smoking during pregnancy ●