14.1. Billy Johnson iHuman

Complete a SOAP note for the patient using the SOAP note template as a guide. The SOAP note should NOT be in a table format. This assignment should be done in a single-spaced Word document.


Billy Johnson Ihuman questions Chief Complaint – Billy Johnson is a reliable 13-year-old boy who presents with his mother, Karen Bloom, with complaints of not wanting to attend school. HPI History is obtained from mother and son. Billy Johnson is a 13-year-old boy who presents with difficulty in school. Per the patient’s mother Billy’s teachers are concerned with his disruptive behavior, inability to follow directions, forgetfulness, inattentiveness, and impatience. They also report that he is unorganized with his belongings (locker and school bag) and not prepared for class. At home, Billy is snapping at his mother and procrastinating with schoolwork. The mother denies any physical emotional or sexual trauma. At home Billy’s mother finds him to be fidgety, restless, irritable, and anxious. Billy’s football coach has also found him to be distracted during practice stating, “he needs o get his head in the game”. Billy’s mother reports overhearing his friends refer to him as bossy or annoying. His friends are “nice kids, not top students”. Billy had a rough time with the recent divorce but after a schedule was initiated, he is more comfortable with it. Billy does not follow a diet but his mother limits the amount of red food dye in the home since it seems to negatively affect his mood. Denies depression. The mother also reports Billy was hyperactive as a toddler but grew out of it by the age of ten. Per the patient, Billy, the school makes him feel stupid