I Human, Rebecca Fields Case Study MAY 2023 questions and answers latest updates WITH EXPERTS FEEDBACK AND CORRECT ANSWERS AS PER THE MARKING SCHEME A GRADE.

i human 6 Billy Johnson september CASE STUDY 2023 Edition. Billy Johnson 13 yo “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 ⦁ How can I help you today? ⦁ 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?? ⦁ What has been happening since your last visit? ⦁ This is my first visit??? HOW I HAVE RECORDS FROM ONE YEAR AGO ⦁ Mother: How can I help him today? ⦁ 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 ⦁ Mother: Any other symptoms or concerns we should discuss? ⦁ 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. ⦁ Clicked twice ⦁ Mother: what symptom is most distressing for him? ⦁ He says he feels fine, but I know he’s feeling singled out as a problem kid. ⦁ Mother: how does this affect his life? ⦁ I guess he's not wanting to go to school. ⦁ How are your grades in school? ⦁ Not good ⦁ Are you having difficulty concentrating or making decisions well? ⦁ That's what everyone tells me. ⦁ Mother: is he having trouble concentrating? ⦁ 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. ⦁ Mother: has he been more irritable or angry lately? ⦁ 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. ⦁ Do you have any other symptoms or concerns we should discuss? ⦁ 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. ⦁ Tell me how that makes you feel. ⦁ 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. ⦁ What is your name? ⦁ Where are you? ⦁ What time is it? ⦁ What happened? ⦁ How does this affect your life? ⦁ Not really ⦁ When did your trouble concentrating or making decisions start? ⦁ I don't know i don't know if I really have a problem. They say i'm not paying enough attention ⦁ Mother: when did his trouble concentrating or making decisions start. ⦁ Tell me about your family and friends. Has anything changed? ⦁ Just the divorce a year ago ⦁ Tell me about your boyfriends and girlfriends. ⦁ I have a lot of friends ⦁ Do you or any family members have problems with bullying? ⦁ Nope ⦁ Mother: does he have problems with bullying? ⦁ Not that i know of ⦁ How would you describe your moods? ⦁ I get frustrated if that's what you mean ⦁ Do you feel full of energy? ⦁ 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 ⦁ Mother: are his immunizations up to date? ⦁ Are you taking any prescription medications? ⦁ No, not taking anything ⦁ Are there any diseases that run in your family? ⦁ No ⦁ Health of grandparents, parents ⦁ Ask my mom ⦁ Mother: Health of his grandparents, parents, siblings? ⦁ 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. ⦁ Do you drink alcohol? ⦁ No ⦁ Do you use any recreational drugs? ⦁ No, I've never done drugs. I'm not a bad kid. ⦁ Do you smoke? ⦁ No, my mom would kill me. ⦁ Tell me about daily exercises or sports that you plat. ⦁ I love sports -- basketball and football. ⦁ Mother: does he drink alcohol? ⦁ No ⦁ Mother: does he use drugs? ⦁ No ⦁ Does he now or has he ever smoked or chewed tobacco? ⦁ Have you been depressed? ⦁ No i just don't want to go to school is all ⦁ Tell me about any negative thoughts you have about yourself, other people, the world. ⦁ Don't have the problem ⦁ Are you having any difficulty sleeping? ⦁ Its hard to fall asleep sometimes ⦁ Do you have a problem remembering things? ⦁ Uh...no ⦁ Recurring intrusive thoughts that cause you to engage in repetitive behaviors? ⦁ No ⦁ Do you have racing thoughts or increased energy? ⦁ Everyone tells me i have high energy ⦁ Does he have racing thoughts or increased energy? ⦁ It seems that way ⦁ Do you have trouble with reasoning, planning, or organizing? ⦁ No ⦁ Do you often get bored? ⦁ All the time! ⦁ Mother: does he often get bored? ⦁ In school? He sure does. He mentions it all the time. ⦁ Mother: does he have problems with reasoning, planning, or organizing? ⦁ Nope. ⦁ Mother: what childhood illnesses has he had? ⦁ Nothing out of the ordinary. No abuse. Up Until the divorc our family life was pretty uneventful Hint 2: 15/38 ⦁ 11 more in assoc symptoms ⦁ 2 more in HPI ⦁ 5 more in PMH ⦁ 4 more in SH ⦁ 1 more in etiology ⦁ Mother: has he had any seizures? ⦁ no ⦁ Mother: had he had any significant traumatic injuries or accidents? ⦁ No Never had a head injury or broken bone, ⦁ Are there any diseases that run in his family? ⦁ No ⦁ Mother: Is it difficult to sleep? ⦁ Sometimes ⦁ Do you take anything to help you sleep? ⦁ Ask my mom ⦁ What do you do when you can't fall asleep? ⦁ Nothing ⦁ Mother: does he take anything when he can't fall asleep? ⦁ i occasionally give him melatonin at night, but i'm not sure if it makes a difference ⦁ On average, how many hours do you sleep a night? ⦁ 6-8 ⦁ Have you been feeling sad, depressed, or hopeless? ⦁ School makes me sad. Every day. I ont want to go anymore. ⦁ Negative thoughts again, whoops ⦁ Don't have that problem ⦁ Have you lost interest in things that used to give you pleasure? ⦁ No ⦁ Have you dropped many of your activities and interests? ⦁ No ⦁ Do you feel anxious? ⦁ I'm not sure what that means. I just don't want to go to school ⦁ Are you moving slowly or fidgeting and restless? ⦁ I feel restless lots of times ⦁ Have you had any thoughts of hurting or killing yourself? ⦁ No, of course not. ⦁ Mother: is he moving or speaking slowly or fidgety and restless? ⦁ He can definitely be fidgety or restless at times ⦁ Mother: does he feel anxious? ⦁ Yes, I think I would say that. He seems to have some anxiety related to school. ⦁ Mother: how would he describe his moods? ⦁ 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. ⦁ Is he in good spirits most of the time? ⦁ Most of the time he seems ok. ⦁ Has he recently had any mood or personality changes? ⦁ I wouldn't exactly call it a personality change, but i can say that he is having more and more trouble in school and now he refuses to go ⦁ Mother: tell me about his boyfriends and girlfriends. ⦁ 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 ⦁ Mother: tell me about his family and friends? Has anything changed? ⦁ 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. ⦁ How are his grades in school? ⦁ Dropping ⦁ Idk what i asked ⦁ Mother: is he taking any prescription medications? ⦁ Not a one ⦁ Mother: is he taking any OTC or herbal medications? ⦁ I give him melatonin sometimes. Hint 3: 25/38 ⦁ 6 more in assoc sx ⦁ 3 more in PMH ⦁ 4 more in SH ⦁ Can you tell me about his diet, what does he normally eat? ⦁ He acts crazy with red dyes ⦁ Tell me about your diet, what do you usually eat? ⦁ I eat everything -- at home and at school. I really like burgers and fries. ⦁ DO you drink caffeine or eat chocolate? ⦁ No ⦁ Tell me about your social/leisure activities. ⦁ I like basketball and football. I'm on the football team now ⦁ Are you exposed to secondhand smoke? ⦁ No ⦁ Asked mother about caffeine too ⦁ No ⦁ How is his appetite? Any recent change? ⦁ No ⦁ Cocaine? ⦁ Nope ⦁ Do you feel like you are being punished? ⦁ I don't guess so ⦁ How is your family and family life? ⦁ Divorce a year ago, better now. I like staying with my moms the best. I'm okay with staying at my dad's house one weekend a month. I guess they're both happier now. ⦁ Have you lost interest in or avoided social activities? ⦁ DO you blame yourself for everything wrong? ⦁ No but my teachers sure do ⦁ Have yo had to deal with discrimination? ⦁ No ⦁ Tell me how that makes you feel ⦁ Blah ⦁ Idk ⦁ How does this affect your life? ⦁ I don't want to go to school ⦁ Mother: How is family life? ⦁ Things are fine ⦁ How often do you get the emotional support you need? ⦁ Why do you need to know that? ⦁ Any recurring or intrusive thoughts or behaviors? ⦁ No ⦁ Mother: Is he eating too little or too much? ⦁ No ⦁ Mother: has he lost interest in things that used to give him pleasure? ⦁ No ⦁ Does he feel like he is being punished? ⦁ More like singled out ⦁ What time does he go to sleep? ⦁ Around 9 or 10 ⦁ Mother: how is his overall health? ⦁ 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, id say that its not too severe. ⦁ Can you tel 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, evi or other lesions ⦁ Inspect and palpate neck ⦁ No visible scars on neck, no deformities or other lesions, trachea is midbline 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, irritabl 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-testng eros ⦁ 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 ⦁ ADHD - Lead ⦁ Hyperthyroidism - MnM ⦁ TSH ⦁ Generalized anxiety disorder ⦁ Substance use disorder - MnM ⦁ Drug toxicology, urine ⦁ 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