IHUMAN CASE STUDY: MR. JUSTIN JOHNSON 19 Y/O MALE CC: TRESSPASSING, MAKINGFALSE CLAIMS

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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 in “quotes” Statement from Mother “Jus... tin 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 This study source was downloaded by 100000844708667 from CourseHero.com on 08-31-2022 01:07:23 GMT -05:00 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: This study source was downloaded by 100000844708667 from CourseHero.com on 08-31-2022 01:07:23 GMT -05:00 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 This study source was downloaded by 100000844708667 from CourseHero.com on 08-31-2022 01:07:23 GMT -05:00 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), This study source was downloaded by 100000844708667 from CourseHero.com on 08-31-2022 01:07:23 GMT -05:00 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) This study source was downloaded by 100000844708667 from CourseHero.com on 08-31-2022 01 [Show More]

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