I HUMAN WEEK 13:JUSTIN JOHNSON 19 YEARS OLD MALE CC;PROBLEM AT SCHOOL REVIEW AS PER MARKING SCHEME WITH ACTUAL 100%CORRECT ANSWERS.
Case Study
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Johan Bello
IHuman week 13
Regis College
Class: NU-664C-02-20PCFA FamilyPsychiatric Ment.Hlth I
Psychiatric SOAP Note Template
Criteria Clinical Notes
Subjective Patient name: Justin Johnson
Gender: Male
Age: 19 y/o
Chief complaint: c/o problems at school
HPI (History of present illness): The patient (Justin Johnson) is a 19 y/o male who presents was accompanied by his mother and presented with c/o problems at school. The patient reports that he was expelled from college two months ago for breaking into a building on campus and shouting that the dean wanted to steal his intellectual property. The patient’s mother reports that his behavior started changing about six months ago after he stopped taking his medication
(methylphenidate) for Attention-deficit hyperactive disorder. Additionally, the patient admits he had stopped attending classes and began to smoke more marijuana. Moreover, he
states that he was detached from social interaction and seemed to be “obsessed” with research, specifically in academic plagiarism. His mother reports that she had observed manifestations of paranoid ideation as well as ritualistic behaviors in the patient over the past two months while at home, he had neglected his personal hygiene, slept during the day, and avoided engaging in activities that were previously enjoyable. Notably, the patient had repetitive head-tilting movements, staring spells, and scratching of the left ear.
Past medical and psychiatric history: The patient has a h/o childhood asthma (he used an albuterol inhaler and his last episode of asthma occurred when he was ten years old) and ADHD. Additionally, the patient had a single and brief episode of fear to leave the house and talking to himself at the age of thirteen years, which was attributed to the type of ADHD medication he was using. However, his behavior returned to normal after his medication was changed.
Social history: Justin is a male student who
was expelled from college recently. He reports the use of marijuana and detachment from social interaction.
Family history: Justin’s paternal uncle has a h/o mental illness and his maternal aunt has a h/o seizure disorder. [Show Less]