Adolescent Focused Note.

Patient Information

Initials: P.O

Age: 18 years

Sex: Female

Race: White American

Subjective

CC (chief complaint): missed menses for the last 5 months, and unintended weight loss (8kgs) in the last one year

HPI: The patient was a female White American adolescent aged 18 years old who presented with complaints of missed menstrual periods for 5 months. She associated the missed menses with unintentional weight loss of 8kgs over the past one year but denied having any changes in appetite. Adolescent Focused Note.

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Current Medications: none

Allergies: none

PMH: up to date with all immunizations, no history of a chronic underlying illness.

Soc & Substance Hx: currently, she lives with both her parents; elder brother, and sister. She reportedly split with her boyfriend six months ago and has not engaged in other sexual relations. She acknowledged drinking   8 units of alcohol in a month and is a non-smoker. She denied illicit and recreational drug use. She is still a student pursuing a course in fashion design and part-time works as an actress and fashion model.Adolescent Focused Note.

Fam Hx:  mother and father are alive and well.  She has a brother and sister aged 26 years and 23 years respectively. No history of chronic underlying medical illnesses.

Surgical Hx: no history of previous major or minor surgeries.

Mental Hx: no history of depression, mental illnesses, self-harm, homicidal or suicidal ideation.

Reproductive Hx:

1. Age of menarche: 13 years old
2. LMP: cannot recall the exact date
3. Menstrual Pattern: a 28-day cycle
4. Duration of flow: 5 – 6 days
5. Amount of flow:  Day 1 and 5 light flows and  day  2-3 moderate flows
6. Associated pain with menses: no associated pain
7. Intermenstrual bleeding: no intermenstrual bleeding
8. Menopause: not applicable. Adolescent Focused Note.

Contraception:

1. Current Method of Satisfaction: currently, the patient does not use   an injectable, oral, implant, or IUD contraceptive but uses   condoms   as the preferred method of  contraception

Infections:

1. Bacterial Vaginosis treatment in January 2020
2. Vaginal Candidiasis (March 2019) Adolescent Focused Note.

Sexual History:

1. The patient identified herself as a heterosexual. Currently, she was not in a sexual relationship but engages in protected sexual intercourse 3 to 4 times a week.
2. No reports of past or current sexual assault.
3. No changes to libido.

Review of Systems (ROS)

General: the patient presented in the office independently. She reported unintentional weight loss (8kgs in the past one year) but denied chills, fever, sore throat, night sweats, and changes in appetite. Adolescent Focused Note.

Integumentary/Skin: the patient denied any changes in skin color or integrity, or acne, open sores or wounds on the trunk, lower and upper extremities.

HEENT: denied trauma to the head, headache, or dizziness. She further denied any changes in vision or hearing, hearing loss, eye discharge, ringing, and discharge from the ears. She denied sores and ulcerations on the gums, tongues, and cheeks, denied pain and difficulty in swallowing, hoarseness, and loss of taste. She flosses and brushes her teeth  2-3 times daily using natural fluoride-free toothpaste, her last dental checkup was three months ago,  she denied having any dental caries, loss of smell, recurrent nosebleeds, and nasal discharge. She denied any swelling or lumps in the back and front of the neck or pain with movement. Adolescent Focused Note.

Breast: the breasts are symmetrical and of the same size. She denies any breast lumps and discharge from the nipples. The nipples protrude forward. The patient states that she conducts monthly self-breast exams and has never felt an abnormal lump.

Cardiovascular/Peripheral Vascular: the patient denies palpitations, chest pains, inability to take part in sports and physical activity; she denies a history of murmurs, swelling of the upper and lower extremities and the face.Adolescent Focused Note.

Respiratory:  the patient denies shortness of breath (SOB), and difficulty breathing with or without activity. She further denied coughs, and wheezing, exposure to influenza, TB. She denies a recent history of respiratory disease or infection. She also denies frequent exposure to second-hand smoke at work or at home.

Gastrointestinal: appetite is satisfactory. She acknowledges unintentional weight loss (8kgs over the past one year). She denies vomiting, diarrhea, and nausea. She further denies constipation, dietary changes, changes in bowel habits, and abdominal pain. Adolescent Focused Note.

Genitourinary: the patient denies changes in bladder and bowel habits, denies frequency and urgency, denies pain with urination, denies a burning sensation on urination, lower back pain, foul-smelling vaginal discharge, and urine.  She denies having vaginal sores but does not recall the exact date of the LMP.

Musculoskeletal: the patient denies lower and upper extremities, joints, back or neck swelling and pain, denies difficulties in movement. The patient acknowledges using seat belts during every ride. Adolescent Focused Note.

Psychiatric: patient denies a history of depression or mental illnesses, emotional disturbances, feeling blue or sad, extreme tiredness, auditory and visual hallucinations, self-harm, suicidal and homicidal thoughts. Adolescent Focused Note.

GYN: denies vaginal and anal sores, doesn’t remember the exact date of the LMP, has a 28-day cycle with a regular flow, denies dysmenorrhea and inter-menstrual bleeding. She denies excess vaginal discharge, denies vaginal discharge with a foul-smelling odor, denies exposure to an STI, and denies vaginal itching. Denies engaging in high-risk sexual behavior such as anal sexual intercourse but consistently engages in safe sex. Adolescent Focused Note.

Neurologic: The patient denies memory loss, headaches, seizures, tingling or numbness in the face, lower and upper extremities, denies dizziness, and LOC.

Endocrine: the patient denies feeling excess thirst, increased micturition, cracked skin, and changes in the color, consistency, and integrity of nails and hair, patient reports weight loss (8kgs over the last one year). She acknowledges the excess growth of hair on the legs, face, and forearms. Adolescent Focused Note.

Hematologic/lymphatic: the patient denies familial and self-history of anemia, denies   spontaneous bleeding and bruising, denies history of easy bruising, cuts, and prolonged healing, denies  cold  or blue lips,

Allergic/immunologic: the patient denies environmental, medications, and food allergies.

Objective

Vital Signs: Temp: 97.9 °F, BP- 95/60 PR-51bpm and regular, RR-16, O2 sat-99% RA, Height- 1.7m, Weight-41kgs.

General Appearance: The patient is A&O x4, with no muscle mass on the buttocks and limbs.

Gastrointestinal: on inspection, there are no visible deformities, the abdomen is soft and non-tender, and no tumors or masses are protruding with percussion and palpation. The skin is warm and dry with no wounds or rashes. The umbilicus is deep and inverted, dry, and clean with the absence of sores or discharge.  The general tone and color are consistent with the patient’s ethnicity and race. On auscultation, bowel sounds were active and present in all the four quadrants of the abdomen with no palpable masses. The liver span is 10.8 cm, there is dullness over the liver on percussion, and there is no rebound tenderness. Adolescent Focused Note.

Genital/Rectal:

1. External Genitalia

Vulva/Labia Majora: the skin is intact and moist with no edema or erythema

Bartholin Gland:  moist, soft, and pink with no enlarged area or bulging

Skene’s: moist and pink

Clitoris: the hood skin is intact, hyperpigmented, pink, and round.

Urethra: moist and pink with no abnormal discharge and lesions when asked to contract and release the muscles of the pelvis.

Bladder: non-tender with no palpable masses on palpation

Vagina: clear, thin, and odorless vaginal discharge with no odor, vaginal walls are pink with no atrophy, lesions, abnormal discharge, or bruising. The pattern of hair growth is normal and there are no signs of parasitic infections.

Cervix: smooth, pink, round, and moist.  The cervical os is central on the cervix (1cm); it has a   white clear mucoid discharge, no visible abnormalities. Adolescent Focused Note.

Adnexa: no tenderness with manipulation of the speculum, no palpable masses,

Diagnostic results:

Complete Blood Count

Hemoglobin- 14.9 g/dL

MCV – 85 Fl

WBC- 4.5 %

Platelets- 368%

Renal Panel (mmol/L)

Sodium- 138

Potassium- 3.0

Chloride- 92

Bicarbonate- 34

Urea- 4.5

Creatinine- 40

Random Blood Glucose (RBS): 5.6 mmol/L

Albumin- 43 g/L

PDT (pregnancy detection test)-negative

Assessment

Differential Diagnoses

Anorexia nervosa: the patient had a history of secondary amenorrhea from the subjective data, and on the objective data, she had a BMI of 14.0, excess growth of hair on the forearms, cheeks, and neck, and loss of muscle mass on the buttocks and limbs. The laboratory diagnostic tests revealed hypochloremia, hypokalemic, metabolic alkalosis, and this finding meets the criteria of anorexia nervosa.  This is an eating disorder that is commonly diagnosed among young adults and teenagers which is usually characterized by severe loss of weight, amenorrhea and is common in women as compared to men working in areas that prioritize a person’s physical/individual image such as actresses, models, and fashion designers (Harrington et al, 2015).  It often has potential triggers such as an emotional upset from a breakup.  Besides, patients usually have hypotension and sinus bradycardia as demonstrated by the vital signs of a BP- 95/60 PR-51bpm and regular. Adolescent Focused Note.

Hypothyroidism: the patient presented with a history of secondary amenorrhea for 5 months. On examination, there was also increased hair loss on the face, cheeks, and legs although she denies any heat or cold intolerance (Dunn & Turner, 2016). To rule out this diagnosis, it will be important to conduct a thyroid function test. Adolescent Focused Note.

Binge Eating Disorder: the patient-reported weight loss of 8kgs over 12 months which was supported by the findings of a BMI of 14 and loss of muscle mass over the buttocks and limbs (Amianto et al (2015).  However, since the patient reported no changes in her appetite and bowel habits, it is a less likely diagnosis. Adolescent Focused Note.

Plan

The patient was referred to a specialist on eating disorders for a possible hospitalization for nutrition intervention for weight gain using a high-calorie diet. The patient was also linked with a psychotherapist for supportive psychotherapy for how she wrongly perceived her body image. Adolescent Focused Note.

Reflection

This clinical experience was the most interesting since it required a high index of suspicion and application of theoretical knowledge into clinical practice to make the most accurate diagnosis. According to Schmidt et al, (2016), eating disorders especially bulimia nervosa and anorexia nervosa are potential causes of mortality and morbidity among females with significant morbidity and mortality in the US. The author also learned the significance of NPs collaborating with multidisciplinary team members of nutritionists, and psychiatrists to manage patients with eating disorders successfully. Adolescent Focused Note.