Case
iHuman 6 billy johnson case study
PSY MISC i-human_6_-_Billy_Johnson
Billy Johnson
13 yo
“I hate school”
With his
... [Show More] mother
Observations
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Fidgeting
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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.
Hint 1: 5/38
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14 more in associated symptoms
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2 more in HPI
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6 more in PMH
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9 more in SH
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1 more in FH
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1 more in etiology
Missed
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Patient
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Do you have a problem with fatigue/tiredness?
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No i have a lot of energy i am a kid
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WItness
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Does he have a problem with depression?
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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
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Has he dropped many of his activities and interests?
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no
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Is his anxiety better or worse at any time of the day, week, or year?
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He says he feels better staying home from school and he does sleep better on the weekends.
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Can you describe a typical night's sleep for him?
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He always gets to sleep within an hour or so, id say that its not too severe.
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Can you tel me about any current or past medical problems he has had?
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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.
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Were there any complications in his birth?
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No, very easy and normal. Full term vaginal delivery. Smoked until 2nd trimester them quit
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Is he sexually active?
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No but he does seem to be developing quite normally in that regard
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Tell me about daily exercises or sports that he plays.
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He likes team sports. He is on the football team and his coach is complaining that he won't follow directions
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Physical Exam
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Inspect skin overall
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Skin is warm, dry and no lesions are seen [Show Less]