Patient Information: EH, 16-year-old, Caucasian, Female
Subjective:
CC (chief complaint): Recent weight loss reported by family
HPI: 16 y/o, WF,
... [Show More] accompanied by her mother with concerns overs weight loss. Reports having
lost 30 lbs total in the last year, 20 lbs in past 6 months. The patient states she will wake up in the
middle of the night to exercise, uses laxatives, and restricts calories. Admits to binge eating
followed by self-induced vomiting. BMI is 15.7. Episode of syncope a few days ago. Menstrual
irregularities and has not had a period in 3 months. Denies pregnancy and reports has not been
sexually active in 1 year. Parents divorced 1 year ago. She denies depression, admits being
anxious about how she is perceived by others. Mother reports concerns about depression and loss
of interest. Recent left metatarsal fracture. Physical exam, patient is noticeable cachexic with fine
thinning hair, cracked lips, mild angular cheilitis, and abrasions and calluses on the dorsum of
her right hand. She is bradycardic with orthostatic hypotension. No laboratory studies to review
yet.
Current meds: None
Allergies: NKDA
Pertinent PMHx:
Immunizations: Up to date for age.
Social hx: Parents are recently divorced and Elisa lives between both homes currently.
Fam Hx:
History Questions Asked:
1.
ROS:
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GENERAL: Alert and oriented.
HEENT: No runny nose, eye or ear discharge. No reports of conjunctivitis.
SKIN: No rashes, bruising or petechiae. Abrasions and calluses reported to right hand.
CARDIOVASCULAR: No history of murmurs, gallops or rubs. RESPIRATORY:
Denies any SOB, cough, wheezing or difficulty breathing. GASTROINTESTINAL: Admits
to binge eating and self-induced vomiting, with frequent use of laxatives.
GENITOURINARY: Denies any burning or trouble urinating.
NEUROLOGICAL: No history of seizures or headaches. Syncopal episode x1 last
week.
MUSCULOSKELETAL: Recent left metatarsal fracture.
LYMPHATICS: Denies any lymph node enlargement.
HEMATOLOGIC: Denies anemia, unexplained bruising or bleeding.
PSYCHIATRIC: Denies depression. States she is sometimes anxious about how she is
perceived by others. Mother states she has a loss of interest in things and depression.
ENDOCRINOLOGIC: Denies excessive sweating, thirst, or urination. Denies heat or
cold intolerance.
ALLERGIES: Denies frequ [Show Less]