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 changed.
He is concerned peo
...
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 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
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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
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