Pediatric Case Write Up

Topics: Menstrual cycle, Combined oral contraceptive pill, Pregnancy test Pages: 6 (1676 words) Published: June 4, 2011
ID: D.C is a 17 year old Puerto Rican female

CC: “I missed my period”

Source: History was taken from patient and she is reliable

17yo F with PMH of anorexia nervosa and depression presents to the adolescent clinic with the complaint that she missed her period. She stated that her last menstrual period was November 4th, and that it was supposed to come on December 3rd, as she usually has a 29 day cycle. She stated that her periods have always been regular and the only time she missed her period before this was 2 years ago when she was given the diagnosis of anorexia nervosa. At that time, she missed 4 periods consecutively. The patient stated that she has since been seeing a private psychiatrist for therapy and no longer has anorexia, but admits that she has unintentionally lost 10 pounds in the past 6 weeks. She denies excessive sweating, palpitations and anxiety. She states that she feels tired and fatigued at times. She denies binging, purging, excessive exercise, laxative use, or any changes in her diet, and states that she has good self image. The patient was on the oral contraceptive pill Loestrin for the past 2 years, but quit taking the pill one month ago in the hopes that she could become pregnant and have a baby with her boyfriend. She denies current symptoms of depression, but has been on antidepressants for the past two years. She denies headache, vision changes, galactorrhea, decreased libido or vaginal dryness. She also denies feeling stressed.

Chronic illnesses: Diagnosed with Anorexia Nervosa and Depression in February 2009, for which she has regularly followed up with her private psychiatrist. No history of recurrent infections, STIs, dysmenorrhea or Ovarian cysts Surgery: none

Prozac (fluoxetine) 20mg capsule x mouth daily
Seroquel (quetiapine) 25mg tab x mouth daily
Allergies: No known allergies to any foods/pollen/dander etc Immunizations: Up to date
Ob/GYN: First menstrual period at the age of 11, always regular, lasting 4-5 days. She normally uses 3-4 pads on her heaviest days. Last menstrual period was November 4th which is about 2 months prior to the current date. Last Pap Smear was 4 months ago and was normal.

FH: Mother is without medical illnesses and patient has no information on her father as she did not grow up with him. According to patient, there is no family history of cancer, HTN, DM, or ovarian diseases.

SH: The patient was born in Puerto Rico and lived there until the age of 5. She moved to the US with her mother and currently lives in an apartment in Queens. She dropped out of school in September 2010 and was in the 9th grade at the time. She stated that she should have been in 12th grade by now but it was very difficult for her to pass math and english and therefore had to remain in the 9th grade. She denies any delays in developmental milestones such as walking, talking and potty training and also denies ever needing special education classes. She plans to get a GED. She doesn't have a job but states that she is actively looking for one. She has many friends and enjoys listening to music and watching movies with them. She denies smoking, the use of alcohol or any illicit drugs such as marijuana, cocaine or heroine. Her diet consists of 5 small meals throughout the day, and she eats vegetables, chicken, granola bars, fruits and pasta. She has been sexually active since the age of 14, and has had a total of 5 partners since. She has never had an STD and last HIV test was in September and was negative. She has been in a relationship with her current boyfriend for the past 8 months and the two of them have recently decided to have a baby. The patient stated that her mother gave birth to her at the age of 15 so it's time for her to "catch up." She plans to move in with her boyfriend once she becomes pregnant. Her boyfriend also dropped out of school and is without a job.

General: +weight loss, +tiredness & fatigue
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