Lily 15 ½ year old female
Subjective
Chief complaint: Desire to play sports, mother reports Lily hasn‟t had menarche since 14th
birthday
History of present illness (HPI): Lily is brought in by her mother Kayla for a sports physical as
she would like to play volleyball prior to the initiation of school. Mother is also concerned
because Lily had menarche at age 13 with 4 periods that year, but none since her 14th birthday.
She is now 15 and ½ years old. She expresses angst at starting a new school and leaving her
friends for the recent move. Her mother reports she would also like to begin Lily on „the pill‟,
because “I don‟t want her getting pregnant young like I did”. Her mother remains present
throughout the gathering of the history.
Past Medical History: NKDA. No current medications. Includes being a full-term vaginal
delivery weighing 6 lb 4 oz. She experienced a right radial fracture at age 8 and tonsillectomy
and adenoidectomy at age 9.
Vaccination: Mother states, “She had all of her shots up to kindergarten, but I don‟t think she has
needed any since then.”
Family History: Kayla (mother) and father are smokers. The mother has been a smoker since age
22 at one pack-per-day until 18 months ago. The father continues to smoke. There were no
diseases reported in either parent. Kayla has a history with gestational diabetes. Mary has a
history of hyperlipidemia, Type 2 DM, and Hypertension. Tom has a history of hypertension,
hyperlipidemia, and an MI with stenting 2 years ago. The mother has two siblings; one who died
in an MVA 5 years ago at the age of 18 a younger brother, and an older sister who is 42 and lives
in a large urban city in the Midwest with her family, and she is in good health but also had PCOS
and difficulty conceiving. Other family members died of old age. She is unaware of paternal
familial health history.
Social History: Sophomore in high school, sleeps 7-8 hours a night, she is dating a local boy not
currently sexually active. No drug usage or alcohol usage.
Review of Systems:
Constitutional: Weight gain or weight loss? Fever or chills? Change in appetite? Do you or have
you had weakness or fatigue?
Neurologic: Do you have headaches, loss of consciousness, dizziness, syncope or
numbness/tingling in the extremities? Do you have history of sustaining head trauma or
concussion? Any history of loss of consciousness or seizures? Do you ever drink or use drugs
when you are alone?
Head/Eyes/Ears/Nose/Mouth/Throat: visual loss, blurred vision, pain, redness or discharge from
the eyes? Do you wear corrective lenses? Have you had any trauma to the eyes? Any hear loss or
changes? Do you have sore throat, difficulty swallowing or change in taste?
Integumentary: Do you have piercings or tattoos? Any skin lesions or infections?
, Cardiovascular: Any discomfort, pain, tightness, or pressure in your chest when exercising? Any
heart murmurs?
Respiratory: have you or do you become short of breath when exercising or completing daily
activities or tasks? Do you have a history or asthma, wheezing, dyspnea with activities or other
pulmonary problems?
Genitourinary: Reports no menses. Do you have abnormal vaginal bleeding? Have you ever used
any kind of contraceptive devices or methods? Do you have pain or burning when urinating? Are
you sexually active? If yes, do you have multiple sexual partners? Do you use condoms every
time you have intercourse?
Gastrointestinal: Any nausea, vomiting, or diarrhea?
Musculoskeletal: Any history of sprains, strains fractures, dislocations or subluxations? Do you
have muscle weakness, back pain, joint pain or stiffness?
Hematologic: Are you abnormally fatigues experience abnormal bruising or bleeding?
Endocrine: not reviewed
Psychiatric: Do you feel anxious or depressed? Do you have any sleeping problems at night?
Any significant changes in your life recently? Are you taking any prescribed or herbal
supplements? Have you ever taken diet pills? Have there any changes to your eating habits? Do
you have body image concerns? Have you ever been bullied?
Assessment
Based on the physical exam findings what are your primary, secondary, and differential
diagnoses now?
Primary Diagnosis:
1. Sports physical (ICD 10: Z02.83)- is a clinical examination used to evaluate athletes for
injuries, illnesses, or other conditions that might increase the risk of harm to themselves
or others when participating in sports
Secondary Diagnosis:
2. Secondary Amenorrhea (ICD 10: N91.2) - Amenorrhea is the transient or permanent
absence of menstrual flow and may be subdivided into primary and secondary
presentations, relative to menarche. Lack of menses in a non-pregnant female for at least
3 cycles of her previous interval, or lack of menses for 6 months in a patient who was
previously menstruating (Andreeff, 2014).
3. Underimmunization (ICD 10: Z29.3) - The patient has not had immunizations since
kindergarten and is in need of further immunization (CDC, 2017)
4. Stress (ICD 10: F43.0) - According to Karim (2013) the hypothalamus releases
corticotropin-releasing hormone (CRH), vasopressin, which activate the HPA axis. CRH
Subjective
Chief complaint: Desire to play sports, mother reports Lily hasn‟t had menarche since 14th
birthday
History of present illness (HPI): Lily is brought in by her mother Kayla for a sports physical as
she would like to play volleyball prior to the initiation of school. Mother is also concerned
because Lily had menarche at age 13 with 4 periods that year, but none since her 14th birthday.
She is now 15 and ½ years old. She expresses angst at starting a new school and leaving her
friends for the recent move. Her mother reports she would also like to begin Lily on „the pill‟,
because “I don‟t want her getting pregnant young like I did”. Her mother remains present
throughout the gathering of the history.
Past Medical History: NKDA. No current medications. Includes being a full-term vaginal
delivery weighing 6 lb 4 oz. She experienced a right radial fracture at age 8 and tonsillectomy
and adenoidectomy at age 9.
Vaccination: Mother states, “She had all of her shots up to kindergarten, but I don‟t think she has
needed any since then.”
Family History: Kayla (mother) and father are smokers. The mother has been a smoker since age
22 at one pack-per-day until 18 months ago. The father continues to smoke. There were no
diseases reported in either parent. Kayla has a history with gestational diabetes. Mary has a
history of hyperlipidemia, Type 2 DM, and Hypertension. Tom has a history of hypertension,
hyperlipidemia, and an MI with stenting 2 years ago. The mother has two siblings; one who died
in an MVA 5 years ago at the age of 18 a younger brother, and an older sister who is 42 and lives
in a large urban city in the Midwest with her family, and she is in good health but also had PCOS
and difficulty conceiving. Other family members died of old age. She is unaware of paternal
familial health history.
Social History: Sophomore in high school, sleeps 7-8 hours a night, she is dating a local boy not
currently sexually active. No drug usage or alcohol usage.
Review of Systems:
Constitutional: Weight gain or weight loss? Fever or chills? Change in appetite? Do you or have
you had weakness or fatigue?
Neurologic: Do you have headaches, loss of consciousness, dizziness, syncope or
numbness/tingling in the extremities? Do you have history of sustaining head trauma or
concussion? Any history of loss of consciousness or seizures? Do you ever drink or use drugs
when you are alone?
Head/Eyes/Ears/Nose/Mouth/Throat: visual loss, blurred vision, pain, redness or discharge from
the eyes? Do you wear corrective lenses? Have you had any trauma to the eyes? Any hear loss or
changes? Do you have sore throat, difficulty swallowing or change in taste?
Integumentary: Do you have piercings or tattoos? Any skin lesions or infections?
, Cardiovascular: Any discomfort, pain, tightness, or pressure in your chest when exercising? Any
heart murmurs?
Respiratory: have you or do you become short of breath when exercising or completing daily
activities or tasks? Do you have a history or asthma, wheezing, dyspnea with activities or other
pulmonary problems?
Genitourinary: Reports no menses. Do you have abnormal vaginal bleeding? Have you ever used
any kind of contraceptive devices or methods? Do you have pain or burning when urinating? Are
you sexually active? If yes, do you have multiple sexual partners? Do you use condoms every
time you have intercourse?
Gastrointestinal: Any nausea, vomiting, or diarrhea?
Musculoskeletal: Any history of sprains, strains fractures, dislocations or subluxations? Do you
have muscle weakness, back pain, joint pain or stiffness?
Hematologic: Are you abnormally fatigues experience abnormal bruising or bleeding?
Endocrine: not reviewed
Psychiatric: Do you feel anxious or depressed? Do you have any sleeping problems at night?
Any significant changes in your life recently? Are you taking any prescribed or herbal
supplements? Have you ever taken diet pills? Have there any changes to your eating habits? Do
you have body image concerns? Have you ever been bullied?
Assessment
Based on the physical exam findings what are your primary, secondary, and differential
diagnoses now?
Primary Diagnosis:
1. Sports physical (ICD 10: Z02.83)- is a clinical examination used to evaluate athletes for
injuries, illnesses, or other conditions that might increase the risk of harm to themselves
or others when participating in sports
Secondary Diagnosis:
2. Secondary Amenorrhea (ICD 10: N91.2) - Amenorrhea is the transient or permanent
absence of menstrual flow and may be subdivided into primary and secondary
presentations, relative to menarche. Lack of menses in a non-pregnant female for at least
3 cycles of her previous interval, or lack of menses for 6 months in a patient who was
previously menstruating (Andreeff, 2014).
3. Underimmunization (ICD 10: Z29.3) - The patient has not had immunizations since
kindergarten and is in need of further immunization (CDC, 2017)
4. Stress (ICD 10: F43.0) - According to Karim (2013) the hypothalamus releases
corticotropin-releasing hormone (CRH), vasopressin, which activate the HPA axis. CRH
