i human 6 Billy Johnson
CASE STUDY
Billy Johnson
13 yo
“I hate school”
With his mother
Observations
● Fidgeting
● Warm, dry
... [Show More] 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??
2. 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 say that his desk, locker and backpack are messy. He procrastinates when assigned homework and snaps at me when I ask him or remind him about homework. His teachers have also told me that he is constantly ill-prepared for class, including not having pencils or misplacing completed homework assignments. At home he doesn't listen to directions or follow through on his chores -- especially if i give him more than one task at a time.
5. Clicked twice
6. Mother: what symptom is most distressing for him?
a. He says he feels fine, but I know he’s feeling singled out as a problem kid.
7. Mother: how does this affect his life?
a. I guess he's not wanting to go to school.
8. How are your grades in school?
a. Not good
9. Are you having difficulty concentrating or making decisions well?
a. That's what everyone tells me.
10. Mother: is he having trouble concentrating?
a. His concentration is poor at school and at home. I cant remember a day when he was able to do everything we asked when we asked. This has really impacted his schooling and we are at our wits end at home.
11. Mother: has he been more irritable or angry lately?
a. Well he is a 13 year old so its hard to say. He does snap at me when i remind him to do his homework. He tends to procrastinate that a lot.
12. Do you have any other symptoms or concerns we should discuss?
a. I don't have any symptoms. I just don't want to go to school. THey make me feel stupid and im alasyg getting n trouble when its not my fault. Everyone distracts me but i'm the one the teachers say has the problem -- they keep on calling out. Yeah i guess i have a 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.
14. What is your name?
15. Where are you?
16. What time is it?
17. What happened?
18. How does this affect your life?
a. Not really
19. 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
20. Mother: when did his trouble concentrating or making decisions start.
21. Tell me about your family and friends. Has anything changed?
a. Just the divorce a year ago
22. Tell me about your boyfriends and girlfriends.
a. I have a lot of friends
23. Do you or any family members have problems with bullying?
a. Nope
24. Mother: does he have problems with bullying?
a. Not that i know of
25. How would you describe your moods?
a. I get frustrated if that's what you mean
26. Do you feel full of energy?
a. I guess i have a lot of energy
Hint 1: 5/38
● 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
27. Mother: are his immunizations up to date?
28. Are you taking any prescription medications?
a. No, not taking anything
29. Are there any diseases that run in your family?
a. No
30. 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.
35. 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?
a. No
38. Does he now or has he ever smoked or chewed tobacco?
39. Have you been depressed?
a. No i just don't want to go to school is all
40. Tell me about any negative thoughts you have about yourself, other people, the world.
a. Don't have the problem
41. Are you having any difficulty sleeping?
a. Its hard to fall asleep sometimes [Show Less]