Case: 165482 Justin Johnson
Date: 02/06/2021
CC: 19 y/o M/F
Chief complaint is a short 1-2 statement or word phrase
from patient and should be listed
... [Show More] in “quotes”
Statement from Mother
“Justin is having problem, … His behavior has changed.
He is concerned people are spying on him and stealing his
intellectual property… I am worried. He is not the Justin I
know.”
HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts
Justin Johnson, a 19 yr. old patient presented to the clinic with his mother because of change in
behavior that has persisted for 6 months. He was dismissed from school for trespassing and
making false claims against his dean about theft of his intellectual property. The behavior change
happened after he stopped taking his ADHD medication. He was diagnosed with ADHD at the
age of 13. He admits smoking marijuana; has stopped social interactions and going to class. His
mother reports he has been exhibiting paranoid behavior and ignoring self-care.
Onset: Most symptoms 6 months ago while still in school after the stop of
ADHD medications
Location: NA
Duration: Daily and symptoms have persisted for 6 months
Character: Paranoid delusions and auditory hallucinations, and personality
change
Aggravating/alleviating factors: Sore throat is aggravated by cough and
swallowing.
Related symptoms: Bizarre and ritualistic behaviors, irritability, disengagement
from usual activities, staring spells, ADHD -medication cessation, self-neglect,
poor grooming and hygiene, repetitive head, and neck movements.
Treatments: Both patient and mother deny any treatment
Significance: He has been dismissed from school and his mother is distressed
with the change in his personality
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Case: 165482 Justin Johnson
Date: 02/06/2021
PMHx child/adult
illness/hospitalizations/immunizations
ADHD diagnosed at age 13
Childhood asthma
SurgHx type/when/why/complications
No surgical history
FamHx
Grandparents (if known)/Parents/siblings/children
Father: Hypertension
Mother: Depression
Uncle (paternal): Mental illness with 2 hospitalizations
Aunt (maternal): Seizures
SHx
Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationships
Currently living at home after being dismissed from school; He is in his second year of college
Smokes Marijuana 2 times a week but not since he has been home from school
Denies any alcohol use
Reproductive Hx
Female: Age of menarche/menstruation cycle
duration/gravida para status/Childbirth hx/sexual hx and
concerns/LMP/menopause
Breast/cervical screening (if any)
Male: Sexual hx and concerns/issues with fertility (if
any)/Testicular or prostate screening (if applicable)
Screening for STI’s (if applicable)
Denies being sexually active
Allergies (Food, Drug, Environmental, etc.)
NKDA
List of Medications/supplements (prescription, OTC, complementary
alternative therapies)
Albuterol inhaler as needed (not used for years)
Methylphenidate 1omg BID (Patient stopped taking 6 months ago)
Review of Systems: (ROS) Use this column to
document the ROS below.
General: Denies weight gain
Eyes: Deferred
From the ROS: list/highlight the current symptoms/complaints to generate a
list of pertinent “reported or denied” symptoms below:
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Case: 165482 Justin Johnson
Date: 02/06/2021
ENT: Deferred
Pulmonary: Deferred
CV: Deferred
GI: Deferred
GU: Deferred
MS: Deferred
Heme: Deferred
Lymph: Deferred
Endocrine: Deferred
Derm: Deferred
Neuro: Denies any movement problems
Psych: Paranoid delusions, auditory hallucinations,
Repetitive behavior, Personality change, irritability,
staring spells, stopped taking ADHD medication,
poor grooming, Repetitive head and neck
movement, disengagement of social activities.
Denies being depressed or having any thoughts of
self-harm
Pertinent Positive ROS: Change in behavior and personality that coincides with
stopping ADHD medication 6 months prior to clinic visit. Paranoid delusions,
auditory hallucinations, Repetitive behavior, irritability, staring spells, poor
grooming, Repetitive head and neck movement, disengagement of social
activities.
Pertinent Negative ROS: Denies weight gain or loss, denies thoughts of selfharm, and denies any movement problems
Physical Exam: (PE) Use this column to
document the PE below.
Vitals (HR/BP/RR/T/SpO2/Ht/Wt/BMI%)
Temperature: 98.6
Pulse: 74
Blood pressure: 118/82 mmHg - Sitting
Respiratory rate: 16 bpm
SpO2: 100% on room air
Weight: 180 lbs.
Height: 5’10”
BMI: 25.8
From the PE: list/highlight the presence or absence of objective findings to
generate a list of pertinent “(+) or (-)” symptoms below:
Pertinent Positive PE findings: Delusional, auditory hallucinations, refused to
cooperate with MMSE
Pertinent Negative PE Findings: No rigidity. Motor exam normal
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Case: 165482 Justin Johnson
Date: 02/06/2021
General: Slightly obese young man exhibiting
paranoid delusions, hallucinations.
HEENT: Scattered scalp excoriations surrounding
the left ear, without signs of infections.
Normocephalic, atraumatic
Neck: Deferred
Pulm: Respirations regular and unlabored, normal
lung sounds
CV: HR 74. Normal heart sounds
GI: Soft round and no tenderness. Bowel sounds
present in all quadrants
GU: Deferred
Neuro: No rigidity, motor exam normal
MSK: Deferred
Psych: Refused MMSE
Lab/Radiology or other Diagnostic data:
Drug toxicology testing, urine -Positive for Cannabis
(THC) (Detection time 4-6 weeks)
Problem Statement:
Mr. Johnson is a 19 yr. old male patient presenting to the clinic with his mother. His mother
reports he has had a change in behavior that has persisted for 6 months. He was dismissed from
school for trespassing and making false claims against his dean about theft of his intellectual
property. The behavior change happened after he stopped taking his ADHD medication. He was
diagnosed with ADHD at the age of 13 and that is when he was prescribed methylphenidates
after another ADHD medication failed. He admits having smoked marijuana when he was on his
college campus, he stated he smoked about 2 times a week, but he has not smoked so much since
he has been home. He has stopped social interactions and going to class. His mother also reports
he has been exhibiting paranoid behavior and ignoring self-care and shows no motivation to
complete activities of daily living. Mr. Johnson shows sign of poor grooming as evidenced by
body odor. He is slightly obese and denies any recent weight gain or loss. His thought process is
illogical and delusional, and he has auditory hallucinations. He also has repetitive behavior,
irritable and agitated. He has no suicidal or homicidal ideation but has paranoid ideation. He
refused to complete MMSE. Unremarkable physical exam except excoriations on the scalp with
no head trauma. He has a family history of depression without medication treatment (mother),
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Case: 165482 Justin Johnson
Date: 02/06/2021
epilepsy (maternal aunt) and mental illness (paternal uncle). He denies being sexually and denies
any alcohol use. His urine toxicology was positive for cannabis (THC).
IHUMAN TOTAL CASE SCORES:
#1: 57%
#2: 77%
Based on patient’s age/risk factors, what
preventive screening would be recommended
at today’s or a future visit:
Screening for High BP in adults 18 years and
older: Patient is at risk because he is overweight
HIV screening although not currently sexually
active, he has been in the past.
Grade B
Screening for unhealthy drug use in adults 18
years and older: Patient reports marijuana and
has toxicology report positive for cannabis
List the differential diagnoses (Must not
Miss/Leading/Alternate/Concluding)
*Include ICD 10 codes after each
Must not Miss/Leading
Schizophrenia (F20.9): The presenting signs and symptoms of delusions, hallucinations, poor
grooming, withdrawal from social activity, changes in emotions, lack of motivation, paranoid
ideas and actions and change in sleep pattern are more indicative of schizophrenia more so than
the other differential diagnosis
Absence seizures (G40): No symptoms are indicative of absence seizures although he has a
family history of seizures
Bipolar 1 disorder (f31.9): agitation, irritability, change in behavior and lack of sleep and the
other symptoms characteristic of bipolar is due to delusional thoughts.
Major depressive disorder (F32.9): He denies most of the signs of depression
Obsessive-compulsive disorder (F42). He has repetitive behaviors suggestive of this diagnosis
but limited.
Substance-induced psychotic disorder (F19.951) Member does have history of marijuana use, but
not since he returned home. The symptoms have persisted since cessation.
Schizoaffective disorder (F25.9): Because of the chronic and persistent course of the illness this
diagnosis can be ruled out.
(ICD10data.com, 2021)
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