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.

 

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 de

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