Kayla brings Lily in for a sports 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.
Lily denies any concerning symptoms.
Immunizations: Mother states “She had all of her shots up to kindergarten, but I don’t think she has needed any since then.
Past Medical History: Includes being a full-term vaginal delivery weighing 8 lbs. She experienced a right radial fracture at age 5 and tonsillectomy and adenoidectomy at age 7.
Discussion Questions Part One: We will begin by focusing on gathering history on an adolescent.
What is one important item you learned about gathering a history on an adolescent? For a sports physical?
Did you pick up any ‘red flags’ in the historical data?
What information should always be gathered on an adolescent that you have not previously seen?
What makes a sports physical unique from other exams?
What are your differential diagnoses?
What further history should be gathered today and why?
Discussion Part Two (graded)
Physical Examination of Lily:
V/S: Height- 160 cm, Weight- 45 kg, B/P 114/60, HR 90, RR 16, T 98.7, SpO2 99%
Awake, alert, oriented, cooperative. Difficulty with eye contact. Answers questions in short 1-2 word answers. HEENT: Head is normocephalic
PERRLA, EOMs intact, sclera clear, conjunctiva unremarkable. TM’s dull, grey, with cone of light reflex bil.
Nares patent, oral mucosa pink and moist. All teeth present except final set of molars upper and lower. Good dental hygiene.
Mucous membranes are moist and pink.
Neck: Neck supply without thyromegaly, normal ROM. No lymphadenopathy.
Pulmonary: Chest wall symmetric, respirations even and unlabored. Lungs CTA.
Cardiac: NL S1, S2. No murmurs or rubs. No JVD. No cyanosis, clubbing, or edema. 2+ pulses bilaterally at the carotid artery. 1+ pulses bilaterally at radial, DP, and PT arteries. No murmur or change in cardiac status with 1 min of vigorous activity in the office. Femoral and radial pulses equal bil from right to left and upper to lower.
Musculoskeletal: Able to do deep knee bends, heel-to-toe walking, stand on one leg for 10 seconds each, Adams forward bend negative.
Neurological: DTRs 2/5 throughout. MAE. Full active ROM.
Tanner: Breasts tanner III. Pubic hair Tanner IV
Discussion Questions Part Two
Based on the physical exam findings what are your primary, secondary, and differential diagnoses now?
Are further diagnostics needed, if so why? If not, why not?
Are any guidelines needed for this history and physical that were not used?
Should contraception be discussed this visit?
Does Lily need a pelvic exam?