IHUMAN BILLY JOHNSON CASE STUDY LATEST 2020/2021 COMPLETE SOLUTION
1. How can I help him today?
2. Do you have any other symptoms or concerns we should discuss?
3. How is his overall health?
4. 4. Is he moving or speaking slowly or fidgeting and restless? If so, how often
5. Is he eating too little or too much? No, his appetite seems to be normal for a growing
boy
6. Do you feel anxious? Im not sure what that means. I just don’t want to go to school.
7. Have you been feeling sad, depressed, or hopeless? If so how often do you feel that
way? School makes me sad every day. I don’t want to go to school.
8. Does he feel anxious? Yes, I would say that. He seems to have some anxiety related to
school.
9. Has he dropped many of his activities and interests? Does school count. Just kidding.
No, he’s still involved with all of his usual activities.
10. Does he have problems with depression? The parent wouldn’t call it depression
11. Do you have problems with fatigue/ tiredness? No, I have a lot of energy, I’m a kid
12. Do you have any other symptoms we should discuss? The teacher says he has a focus
problem
13. Any difficulty sleeping? It is hard to fall asleep sometimes
Reason for encounter: the patient refuses to go to school
HPI:
The patient is a 13-year-old boy who presents to the clinic with his mother. His mother brought
him into the clinic with concerns surrounding her son’s refusal to go to school. Billy’s grades
have been dropping and he has been having concentration problems in class, at home and
during recreational sports. His mother reported that he has had these issues since he was a kid.
His father did not want him to get evaluated before but now that the parents have newly
divorced she feels that it is worth seeing a doctor for. The patient feels that he is always getting
in trouble which causes him to feel anxious and depressed.
He is healthy and hit all of his developmental landmarks on time.
He feels like he’s always getting in trouble
He can be fidgety and restless at times
Takes melatonin to sleep occasionally at night
Irritable at times
ROS:
General: denies weight loss, malaise, chills, or night sweats. The patient and his mother are
reliable sources for the health history.
HEENT/ Neck :
negative
Cardiovascular: negative
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, Respiratory: denies cough or difficulty breathing
Gastrointestinal: negative
Genitourinary: negative
Musculoskeletal/ Osteopathic structural examination: negative
Neurologic: difficulty concentrating and multitasking
Integumentary/ breast: negative
Psychiatric: increased anxiety, refusal to go to school, and difficulty concentrating.
Endocrine:
Hematologic/ lymphatic :
Allergic/ immunologic :
Past medical hx:
He is healthy and hit all of his developmental landmarks on time.
Patients mother smoked during the 1st trimester until 12 weeks’ gestation when she found out
she was pregnant.
Mother never did drugs
Mother only had alcohol 2x in her life and that was “way before she was pregnant”
Denies physical or sexual abuse or emotional abuse of the child
Denies that the teen is sexually active
Hospitalizations/ surgery:
No significant traumatic injuries
Preventative health :
Medications:
Melatonin occasionally at night
Allergies: NKDA
Social hx:
This study source was downloaded by 100000832361371 from CourseHero.com on 07-16-2022 10:54:47 GMT -05:00
https://www.coursehero.com/file/158070350/i-human-billy-johnson-docx/
1. How can I help him today?
2. Do you have any other symptoms or concerns we should discuss?
3. How is his overall health?
4. 4. Is he moving or speaking slowly or fidgeting and restless? If so, how often
5. Is he eating too little or too much? No, his appetite seems to be normal for a growing
boy
6. Do you feel anxious? Im not sure what that means. I just don’t want to go to school.
7. Have you been feeling sad, depressed, or hopeless? If so how often do you feel that
way? School makes me sad every day. I don’t want to go to school.
8. Does he feel anxious? Yes, I would say that. He seems to have some anxiety related to
school.
9. Has he dropped many of his activities and interests? Does school count. Just kidding.
No, he’s still involved with all of his usual activities.
10. Does he have problems with depression? The parent wouldn’t call it depression
11. Do you have problems with fatigue/ tiredness? No, I have a lot of energy, I’m a kid
12. Do you have any other symptoms we should discuss? The teacher says he has a focus
problem
13. Any difficulty sleeping? It is hard to fall asleep sometimes
Reason for encounter: the patient refuses to go to school
HPI:
The patient is a 13-year-old boy who presents to the clinic with his mother. His mother brought
him into the clinic with concerns surrounding her son’s refusal to go to school. Billy’s grades
have been dropping and he has been having concentration problems in class, at home and
during recreational sports. His mother reported that he has had these issues since he was a kid.
His father did not want him to get evaluated before but now that the parents have newly
divorced she feels that it is worth seeing a doctor for. The patient feels that he is always getting
in trouble which causes him to feel anxious and depressed.
He is healthy and hit all of his developmental landmarks on time.
He feels like he’s always getting in trouble
He can be fidgety and restless at times
Takes melatonin to sleep occasionally at night
Irritable at times
ROS:
General: denies weight loss, malaise, chills, or night sweats. The patient and his mother are
reliable sources for the health history.
HEENT/ Neck :
negative
Cardiovascular: negative
This study source was downloaded by 100000832361371 from CourseHero.com on 07-16-2022 10:54:47 GMT -05:00
https://www.coursehero.com/file/158070350/i-human-billy-johnson-docx/
, Respiratory: denies cough or difficulty breathing
Gastrointestinal: negative
Genitourinary: negative
Musculoskeletal/ Osteopathic structural examination: negative
Neurologic: difficulty concentrating and multitasking
Integumentary/ breast: negative
Psychiatric: increased anxiety, refusal to go to school, and difficulty concentrating.
Endocrine:
Hematologic/ lymphatic :
Allergic/ immunologic :
Past medical hx:
He is healthy and hit all of his developmental landmarks on time.
Patients mother smoked during the 1st trimester until 12 weeks’ gestation when she found out
she was pregnant.
Mother never did drugs
Mother only had alcohol 2x in her life and that was “way before she was pregnant”
Denies physical or sexual abuse or emotional abuse of the child
Denies that the teen is sexually active
Hospitalizations/ surgery:
No significant traumatic injuries
Preventative health :
Medications:
Melatonin occasionally at night
Allergies: NKDA
Social hx:
This study source was downloaded by 100000832361371 from CourseHero.com on 07-16-2022 10:54:47 GMT -05:00
https://www.coursehero.com/file/158070350/i-human-billy-johnson-docx/
