IHUMAN CASE - JUSTIN JOHNSON PERPETUAL ASEME

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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 “Justin is having problem, … His behavior has ch... anged. 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 100000843285337 from CourseHero.com on 03-06-2023 05:28:23 GMT -06:00 https://www.coursehero.com/file/115175062/IHUMAN-CASE-JUSTIN-JOHNSON-PERPETUAL-ASEMEdocx/ 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 [Show More]

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