Billy Johnson ihuman Case Study

Billy Johnson ihuman Case Study

Billy Johnson

13-year-old

“I hate school”

With his mother

Observations

• Fidgeting
• 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.

History

1. How can I help you today?
   1. 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. Mother: How can I help him today?
   1. 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 there’s so much more going on
3. Mother: Any other symptoms or concerns we should discuss?
   1. 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.
4. Do you have any other symptoms or concerns we should discuss?
   1. I don’t have any symptoms. I just don’t want to go to school. They make me feel stupid and I’m always getting in trouble when it’s 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.
5. Tell me how that makes you feel.
   1. 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.
6. Mother: Health of his grandparents, parents, siblings?
   1. 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.
7. Do you drink alcohol?
   1. No
8. Do you use any recreational drugs?
   1. No, I’ve never done drugs. I’m not a bad kid.
9. Do you smoke?
   1. No, my mom would kill me.
10. Mother: does he drink alcohol?
    1. No
11. Mother: does he use drugs?
    1. No
12. Are you having any difficulty sleeping?
    1. Its hard to fall asleep sometimes
13. Do you often get bored?
    1. All the time!
14. Mother: does he often get bored?
    1. In school? He sure does. He mentions it all the time.
15. Mother: what childhood illnesses has he had?
    1. Nothing out of the ordinary. No abuse. Up Until the divorce our family life was pretty uneventful

16. Mother: had he had any significant traumatic injuries or accidents?
    1. No Never had a head injury or broken bone,
17. Have you been feeling sad, depressed, or hopeless?
    1. School makes me sad. Every day. I ont want to go anymore.
18. Do you feel anxious?
    1. I’m not sure what that means. I just don’t want to go to school
19. Mother: is he moving or speaking slowly or fidgety and restless?
    1. He can definitely be fidgety or restless at times
20. Mother: does he feel anxious?
    1. Yes, I think I would say that. He seems to have some anxiety related to school.
21. Mother: how would he describe his moods?
    1. He can be irritable at times. He says little things make him frustrated. His football coach even says Billy needs to “get his head in the game” and is always distracted and having difficulty following directions.
22. Mother: tell me about his boyfriends and girlfriends.
    1. He’s got plenty of friends, nice kids, not top students and i think he even had a girlfriend last year. But sometimes he does have problems with his friends — I’ve heard that kids think Billy can be bossy or annoying
23. Mother: tell me about his family and friends? Has anything changed?
    1. His dad and I divorced a year ago. He had a hard time during the first couple of months having to go back and forth. He was pretty irritable and refused to do his chores. But he’s doing better now and seems to be happy spending one weekend a month with his dad.
24. Mother: is he taking any prescription medications?
    1. Not a one
25. Mother: is he taking any OTC or herbal medications?
    1. I give him melatonin sometimes.
26. Can you tell me about his diet, what does he normally eat?
    1. He acts crazy with red dyes
27. How is your family and family life?
    1. Divorce a year ago, better now. I like staying with my mom’s the best. I’m okay with staying at my dad’s house one weekend a month. I guess they’re both happier now.
28. Mother: Is he eating too little or too much?
    1. No
29. Mother: how is his overall health?
    1. good

Missed

• Patient
  • Do you have a problem with fatigue/tiredness?
    • No i have a lot of energy i am a kid
  • Witness
    • Does he have a problem with depression?
      • 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
    • Has he dropped many of his activities and interests?
      • no
    • Is his anxiety better or worse at any time of the day, week, or year?
      • He says he feels better staying home from school and he does sleep better on the weekends.
    • Can you describe a typical night’s sleep for him?
      • He always gets to sleep within an hour or so, I’d say that it’s not too severe.
    • Can you tell me about any current or past medical problems he has had?
      • 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.
    • Were there any complications in his birth?
      • No, very easy and normal. Full term vaginal delivery. Smoked until 2nd trimester them quit
    • Is he sexually active?
      • No but he does seem to be developing quite normally in that regard
    • Tell me about daily exercises or sports that he plays.
      • He likes team sports. He is on the football team and his coach is complaining that he won’t follow directions

Physical Exam

• Inspect skin overall
  • Skin is warm, dry and no lesions are seen
• Visual acuity
  • 20/20 R and L eyes
• Test hearing
  • No hearing deficits normal weber and rinne tests
• Inspect and palpate head
  • Non-tender, no rashes, scars, edema, masses, lumps, nevi or other lesions
• Inspect and palpate neck
  • No visible scars on neck, no deformities or other lesions, trachea is midline and freely mobile
  • No asymmetry or accessory respiratory muscle use with quiet breathing
  • Thyroid normal in size and symmetrical, no palpable masses or nodules, no thyroid thrills or bruits
• Neurological: gait and stance
  • Normal gait and posture, fidgeting throughout exam
• Reflex tests – deep tendon
  • 2+ throughout
• MMSE
  • Fair eye contact, irritable affect that brightens as session progresses
  • Occasional distractibility, not hearing the interviewers questions fully the first time or looking away from/past the interviewer
  • Some errors made: serial sevens was ⅗ and WORLD backwards was DRLOW; immediate register and recall intact
• Cranial nerves
  • I-IX intact
• Involuntary movements
  • Fidgeting throughout exam, no other involuntary movements noted

Assessment

• MSAP: impaired attention, focus, and concentration
• Related
  • Multiple behavioral concerns
  • School refusal
  • Anxiety
  • Cognitive- testing errors
  • Initial insomnia
  • Parents divorced within the last year
  • FHx of mother being prescribed a stimulant as a young child and adult
  • Fidgeting
• Unknown
  • Maternal smoking during pregnancy

Differential Diagnosis

1. ADHD – Lead
2. Hyperthyroidism – MnM
   1. TSH
3. Generalized anxiety disorder
4. Substance use disorder – MnM
   1. Drug toxicology, urine
5. Depressive disorder – MnM

Plan

• Discuss medication as first line treatment
• Consider pretreatment ECG if there is a personal history of heart disease, or a FH of unexplained syncope or sudden cardiac death
• Utilize Conners ratings scales, child behaviour checklist (CBCL), and Vanderbilt ADHD scales at baseline for longitudinal monitoring of treatment response at school.
• Monitor weight, blood pressure, and pulse over time
• Consider a non-stimulant trial if the patient fails to tolerate or benefit from a stimulant trial; or, if the parent refuses a stimulant for his/her child.
• Suggest parenting training and behavior modification-plans for augmentation of the medication therapy.

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