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15 y.o. male with behavioral problems

HPI. Patient's CC I don't know" Mom's CC: Behavioral problemsHPI: 15 year old Filipino male brought in by mom for behavioral problems that began with drug use on Halloween (3 mos PTP) Problems consist of drug use, failing grades, running away, skipping school.. 2. Transitioning. Pt admits to

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15 y.o. male with behavioral problems

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    1. 1 15 y.o. male with “behavioral problems” Lausanne Orendain, M.D. January 30, 2009 Adolescent Medicine

    2. HPI Patient’s CC – “I don’t know” Mom’s CC: Behavioral problems HPI: 15 year old Filipino male brought in by mom for behavioral problems that began with drug use on Halloween (3 mos PTP) Problems consist of drug use, failing grades, running away, skipping school. 2

    3. Transitioning Pt admits to having a hard time with transitioning to 9th grade at new school: Bishop Gorman Friends Peers Drug tested twice: negative Grades started to decrease 3 Only 1 same friend, rest of friends at Centennial Private school vs. public school Picked on because he is poorOnly 1 same friend, rest of friends at Centennial Private school vs. public school Picked on because he is poor

    4. Timeline Halloween: Patient drank unknown quantity and type of alcohol, ate pizza and then felt “weird.” Denies knowingly taking drugs by ingesting, drinking, or smoking At home, experienced visual and auditory hallucinations He called his mom 4 Myspace – images move & come out of screen On phone with mom – heard dialtone & momMyspace – images move & come out of screen On phone with mom – heard dialtone & mom

    5. Timeline… continued Stayed home for next 2 days Brought to U.C. on day 3 post-ingestion UDS positive for marijuana Was discharged from U.C. November: Patient insisted on switching to public school Lost relationships with friends and family Began failing all classes Ran away for 3 days Stayed at friend’s house. 5 At home – able to wake up to eat and drink, mom said he was out of it, occ. Confused but arousable. Mom told all his friends/family members that he was a drug user Pt ran out of carAt home – able to wake up to eat and drink, mom said he was out of it, occ. Confused but arousable. Mom told all his friends/family members that he was a drug user Pt ran out of car

    6. Timeline December: Patient was switched to public high school Began skipping school 1st week of January: Was found at home high on marijuana with friend 2nd week of January: Continued to miss school for 13 days Sent home after finals because teacher believed he was intoxicated with alcohol 6 Said failing grades came over He saw no point in going to school until the new semester started.Said failing grades came over He saw no point in going to school until the new semester started.

    7. Intervention Mom grounded patient over Christmas break Mom brought him to 4 sessions with a counselor No meds were taken/given 7

    8. Past Medical History BHx: FT, NSVD, + PNC Mom denies drugs, alcohol, tobacco while pregnant No complications Broken left wrist, right forearm, right elbow from skateboarding & snowboarding No surgeries 8

    9. Past Medical History Diagnosed with ADHD in 7th grade treated with Adderall Stopped by mom because it made him feel “slow” Meds: None ALL: NKDA, no food allergies Development: Doing well (grades As-Bs) until Fall 2008 FHx: Mom has arthritis, migraine headaches No substance abuse, depression, or other psychiatric diagnoses 9 In 8th grade and years previous would get As-Cs, never suspended. In 8th grade and years previous would get As-Cs, never suspended.

    10. Social History Home: Lives with mom. “Latch-key kid” since 11 years old. Education: Currently failing 9th grade. Goal is to finish high school and become stunt double in movies. Activity: Inolved in Lacrosse teams and has been showboarding x 4 years 10 since 3 years ago when older brother moved out Calls himself “independent.”since 3 years ago when older brother moved out Calls himself “independent.”

    11. Social History Drugs: First substance use on Halloween Admitted to alcohol but denies knowing how he had marijuana in his system Smoked marijuana knowingly for first time 1st week of January Denies any other drug use 11 Has had same group of friends for 4 years (mom admits to the same)Has had same group of friends for 4 years (mom admits to the same)

    12. Social History Suicide: Denies ever having suicide ideation/plans. Admits to feeling a little sad Sex: First intercourse last summer. Has had 2 female partners total, vaginal sex only, condom use 100% of the time. Safety: Feels safe at home and at school. 12 Depressed about being grounded, having mom isolate him from friends & family Never been in physical fightsDepressed about being grounded, having mom isolate him from friends & family Never been in physical fights

    13. CRAFFT C – Has not ridden in car with someone who was under the influence R – Does not use to relax A – Does not use when alone F – Did forget events at Halloween F – Family has told him to stop using T – Has gotten into trouble while using * Has > than 2 positive responses 13

    14. Physical exam Vitals: T-98 P-65 RR-16 BP-104/66 Wt 64kg (75%) Ht 174.5cm (50-75%) Gen: WN, WD, Alert, NAD Rest of exam normal and non-contributory including HEENT and skin exam 14

    15. Plan Mom wanted “resources” for her son and drug testing. Patient refused any further counseling. Patient plans to attend school and get better grades this semester Wants to get his driving license this summer. Patient agreed to return to clinic in one month and submit to urine drug testing 15

    16. Substance Abuse Criteria Substance abuse: maladaptive pattern of substance use leading to clinically significant impairment or distress as manisfested by 1 or more episodes in a 12 month period Symptoms do not meet dependence criteria 16 (ex. Absences, suspension, expulsion, poor work performance, neglecting children at home) (ex. Driving cars, operating a machine) (ex. Absences, suspension, expulsion, poor work performance, neglecting children at home) (ex. Driving cars, operating a machine)

    17. Substance Abuse Criteria Recurrent substance use resulting in failure to fulfill obligations at work, school, home Recurrent use in situations where it is physically hazardous Substance-related legal problems Continued use despite social/personal problems 17 (arrests) (arguments with spouse, physical fights)(arrests) (arguments with spouse, physical fights)

    18. Substance Dependence Criteria Three or more occurring at any time in same 12 months: Tolerance – need for increased amounts Withdrawal symptoms Taking substance over longer time period or increased amounts Cut Down – persistent desire & efforts Time spent in obtaining substance Social, work, recreational activities are given up Continues substance use despite knowing problems are likely caused by substance 18

    19. Hallucinogen Derived from Latin term “Alucinari” which means “to wander in mind” Hallucinogen causes distortion of perceived reality vs. a true hallucination when a person has experiences that do not happen “Synethesias” = mixing of senses Hearing colors or seeing smells 19

    20. Percentage of High School Students Who Reported Lifetime Hallucinogenic Drug Use,* by Sex** and Race/Ethnicity,*** 2007

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