I Human Case Study Billy Johnson Soap Note – 13 yrs. Old CC. I hate school
Patient Name: Billi Johnson Gender: Male
Marital Status: Single
Race/Ethnicity: Caucasian DOB: xx/xx/xxxx Age:13 CC: “I hate school”
Billy Johnson, 13 years old, arrived at the clinic with his mother. According to
Billy's mother, he refuses to go to school and struggles with concentration, focus,
and attention. Billy's mother also claims that Billy's teachers and the football
coach have mentioned how easily distracted he is.
Billy is a little irritable because his parents recently divorced, and he now lives
with either his father or his mother. His mother observes that although he has
struggled in school since he was a youngster, things have gotten worse in recent
months. Billy is getting lower grades. His mother also saw it at home, while
teachers at school noted his lack of focus and irritability. According to teachers,
he is dirty, unprepared for class, misplaces school supplies, and doesn't finish his
homework. His mother adds that his football coach said, "he is usually distracted"
and has difficulty paying attention.
PMHx: Denies. Psychiatric Hx: Denies Surgical Hx: Denies Medications: Denies
Allergies: NKDA
Family Hx: Billy's father is 42 years old and has a history of school issues and
cocaine misuse. Billy's mother, who is 37 years old and in good health, reports
that she used stimulants in college due to learning difficulties. Billy’s parents are
currently divorce.
Social Hx: About a month ago, parents got divorced. Every month, Billy spends
one weekend at his father's place. Billy consumes nutritious meals. Billy's mom
stated he stays away from foods colored red because he "acts crazy." Billy
participates in football and likes to play sports.
Education: Currently in school, but it is having trouble.
Psychiatric Review of Systems:
PAGE 1
, Constitutional:
HEENT: Denies headaches,
GI: Denies vomiting, abdominal pain, constipation, or diarrhea.
GU: Denies hematuria, polyuria, or dysuria.
Neurological: Denies paranoia, denies seizures, and psychomotor changes.
Psychiatric: Reports concentration difficulties, attention, and focus difficulties.
Denies suicidal or homicidal ideations.
Hematologic: Denies hematomas, easily bruising.
Objective:
HR: 80, B/P: 108/76, Respiration Rate: 16 bpm, SPO2: 99%, Weight: 120 lbs. BMI:
20.6,
Height: 5’4”.
Mini Mental Status Exam:
General: The patient is dressed adequately, yet he is fidgeting and appears
anxious.
Speech: Regular rhythm and tone. Speaks in complete sentences.
Mood: Anxious and irritated
Thought content: Logical
Cognition: AAO x 3, impaired attention, focus and concentration.
Insight: Fair
Denies suicidal and homicidal ideations.
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Patient Name: Billi Johnson Gender: Male
Marital Status: Single
Race/Ethnicity: Caucasian DOB: xx/xx/xxxx Age:13 CC: “I hate school”
Billy Johnson, 13 years old, arrived at the clinic with his mother. According to
Billy's mother, he refuses to go to school and struggles with concentration, focus,
and attention. Billy's mother also claims that Billy's teachers and the football
coach have mentioned how easily distracted he is.
Billy is a little irritable because his parents recently divorced, and he now lives
with either his father or his mother. His mother observes that although he has
struggled in school since he was a youngster, things have gotten worse in recent
months. Billy is getting lower grades. His mother also saw it at home, while
teachers at school noted his lack of focus and irritability. According to teachers,
he is dirty, unprepared for class, misplaces school supplies, and doesn't finish his
homework. His mother adds that his football coach said, "he is usually distracted"
and has difficulty paying attention.
PMHx: Denies. Psychiatric Hx: Denies Surgical Hx: Denies Medications: Denies
Allergies: NKDA
Family Hx: Billy's father is 42 years old and has a history of school issues and
cocaine misuse. Billy's mother, who is 37 years old and in good health, reports
that she used stimulants in college due to learning difficulties. Billy’s parents are
currently divorce.
Social Hx: About a month ago, parents got divorced. Every month, Billy spends
one weekend at his father's place. Billy consumes nutritious meals. Billy's mom
stated he stays away from foods colored red because he "acts crazy." Billy
participates in football and likes to play sports.
Education: Currently in school, but it is having trouble.
Psychiatric Review of Systems:
PAGE 1
, Constitutional:
HEENT: Denies headaches,
GI: Denies vomiting, abdominal pain, constipation, or diarrhea.
GU: Denies hematuria, polyuria, or dysuria.
Neurological: Denies paranoia, denies seizures, and psychomotor changes.
Psychiatric: Reports concentration difficulties, attention, and focus difficulties.
Denies suicidal or homicidal ideations.
Hematologic: Denies hematomas, easily bruising.
Objective:
HR: 80, B/P: 108/76, Respiration Rate: 16 bpm, SPO2: 99%, Weight: 120 lbs. BMI:
20.6,
Height: 5’4”.
Mini Mental Status Exam:
General: The patient is dressed adequately, yet he is fidgeting and appears
anxious.
Speech: Regular rhythm and tone. Speaks in complete sentences.
Mood: Anxious and irritated
Thought content: Logical
Cognition: AAO x 3, impaired attention, focus and concentration.
Insight: Fair
Denies suicidal and homicidal ideations.
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