Soap
L.F,15 and 1/2 years, F
S:
CC: “Sports physical, not started menses yet, Birth control pill .
HPI: Kayla brings Lily in for a sport physical, needed prior to the initiation of school,
because Lily would like to play volleyball. Mother is also concerned because Lily has
never started her period and is now 15 and ½ years.
Mother is present throughout your initial history gathering.
Lily will be a sophomore. She expresses angst at starting a new school and leaving her
friends for the recent move. She sleeps 6 to 7 hours per night. She denies current sexual
activity upon questioning or use of drugs and alcohol. She is currently dating a local boy
she met for the last month. 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.
Onset: Not specified. Location: whole body, generalized
Duration: unknown. Characteristics: none
Aggravating Factors: none Relieving factors: n/a
Treatment: n/a.
PMH: full-term vaginal delivery weighed 8 lbs. She experienced a right radial fracture at
age 5 and tonsillectomy and adenoidectomy at age 7.
Current medications: None
Surgeries: None
Allergies: None
, Vaccination History: Mother states, “She had all of her shots up to kindergarten, but I
don’t think she has needed any since then
Social history: Lily will be a sophomore. She expresses angst at starting a new school
and leaving her friends for the recent move. She sleeps 6 to 7 hours per night. She denies
current sexual activity upon questioning or use of drugs and alcohol
Family History: None
ROS
Constitutional: Have you lost or gained weight over time? Do you have change in your
appetite? Do you or have you had weakness or fatigue? Do you or have you had any
fever or chills?
HEENT: Eyes: Do you have any visual loss, blurred, vision, pain, redness, or discharge
from the eyes? Do you wear corrective lenses? Have you had any trauma to the eyes?
Ears/Nose/Throat: Do you have a hearing loss or changes in hearing? Do you feel any
changes in the sense of smell? Do you have sore throat, difficulty swallowing, any
postnasal drip, or changes in taste?
Neuro: 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? Any history of headaches?
Have you” or pinched nerve? Do you have any numbness, tingling, or paralysis of limbs?
Do you ever drink or use drugs when you're alone?
Cardiovascular: Have you ever passed out, felt dizzy, had chest pain, palpitations, heart
murmurs, heat illness, or trouble breathing during exercise?
Any recent viral illness that may indicate cardiomyopathy? Are you experiencing
L.F,15 and 1/2 years, F
S:
CC: “Sports physical, not started menses yet, Birth control pill .
HPI: Kayla brings Lily in for a sport physical, needed prior to the initiation of school,
because Lily would like to play volleyball. Mother is also concerned because Lily has
never started her period and is now 15 and ½ years.
Mother is present throughout your initial history gathering.
Lily will be a sophomore. She expresses angst at starting a new school and leaving her
friends for the recent move. She sleeps 6 to 7 hours per night. She denies current sexual
activity upon questioning or use of drugs and alcohol. She is currently dating a local boy
she met for the last month. 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.
Onset: Not specified. Location: whole body, generalized
Duration: unknown. Characteristics: none
Aggravating Factors: none Relieving factors: n/a
Treatment: n/a.
PMH: full-term vaginal delivery weighed 8 lbs. She experienced a right radial fracture at
age 5 and tonsillectomy and adenoidectomy at age 7.
Current medications: None
Surgeries: None
Allergies: None
, Vaccination History: Mother states, “She had all of her shots up to kindergarten, but I
don’t think she has needed any since then
Social history: Lily will be a sophomore. She expresses angst at starting a new school
and leaving her friends for the recent move. She sleeps 6 to 7 hours per night. She denies
current sexual activity upon questioning or use of drugs and alcohol
Family History: None
ROS
Constitutional: Have you lost or gained weight over time? Do you have change in your
appetite? Do you or have you had weakness or fatigue? Do you or have you had any
fever or chills?
HEENT: Eyes: Do you have any visual loss, blurred, vision, pain, redness, or discharge
from the eyes? Do you wear corrective lenses? Have you had any trauma to the eyes?
Ears/Nose/Throat: Do you have a hearing loss or changes in hearing? Do you feel any
changes in the sense of smell? Do you have sore throat, difficulty swallowing, any
postnasal drip, or changes in taste?
Neuro: 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? Any history of headaches?
Have you” or pinched nerve? Do you have any numbness, tingling, or paralysis of limbs?
Do you ever drink or use drugs when you're alone?
Cardiovascular: Have you ever passed out, felt dizzy, had chest pain, palpitations, heart
murmurs, heat illness, or trouble breathing during exercise?
Any recent viral illness that may indicate cardiomyopathy? Are you experiencing
