Name:  SH

Date: 6/25/2020

Time: 11:AM ET

Age: 16

Sex: Female

SUBJECTIVE

CC:  The chief complaint is that the patient has abnormal vaginal bleeding. While this is a normal occurrence in many teenagers, it could also the sign of multiple long term illnesses, which need gynecological and pediatric follow-up. Strenuous exercise, ovulation, and immaturity of the reproductive mechanisms could all cause bleeding in between menstrual cycles (Grey & Emmans, 2007). 

HPI:  The present symptoms presented around 3 days ago. The patient is not menstruating. The bleeding is minimal and sporadic – mainly spotting, with no pain or discomfort reported by the patient. By relaxing her workout schedule, as well as physical workload, the patient has seen a noticeable reaction in the bleeding. In the early hours of the night, the patient has noticed increased bleeding, but this dissipates as the night wears on. The patient rates the severity of the illness at 5, on a scale of 1-10. 

Medications: The patient is not taking any medication at the moment. 

PMH

Allergies:  None reported

Medication Intolerances: None reported 

Chronic Illnesses/Major traumas- None reported

Chronic Medical Problems: None reported 

Hospitalizations/Surgeries- None reported

Immunizations all prescribe immunizations received

Safety: Good

Exercise and leisure Exercises daily – lifting light weights, and jogging for around 5 km daily. 

Sleep: Used to sleep well; this has however been disrupted by the bleeding. The patient needs to wake up regularly due to emotional stress and the need to change pads, even though the bleeding is minimal. 

Family History: The patient lives with her parents and three younger siblings. The father is a blue collar worker, while the mother is a home maker. The patient actively assists in chores in the house, including caring for her 3 younger siblings. The parents have not underlying conditions that the patient is aware of, neither are her siblings. 

Social History The patient lives in a safe neighborhood, with reasonable social amenities’ provision. The patient is currently an 11th grader in a local school, where she is active in sports. Her diet is healthy, with only occasional fast food treats. She has no drug use history or symptoms. She is not sexually active, or exhibiting any stress or depression signs. The family is reasonably financially stable, and the patient expects to join college once she is done with high school. 

ROS

General 

Good

Cardiovascular

 Good

Skin

good

Respiratory

 good

Eyes

good

Gastrointestinal

 good

Ears

good

Genitourinary/Gynecological

Evidence of bleeding recorded

Nose/Mouth/Throat

Good

Musculoskeletal

good

Breast

good

Neurological

good

Heme/Lymph/Endo Good

Psychiatric: good

OBJECTIVE

Weight     51kg   BMI 20

Temp 35.6

BP 110/70 mm hg

Height – 63 cm

Pulse – 65 bpm

Resp – good

General Appearance

Very fit, and otherwise healthy. 

Skin

Healthy skin uses common deodorants and lotion. 

HEENT

Head: no headache or discomfort reported

Eyes: good eye acuity

Ears: good ear acuity, the eardrum and other parts of the ear otherwise healthy. No pain reported by the patient.

Nose: Pharynx and uvula are normal, as are other areas of the nose. 

Mouth: no nodules, carcinoma, or ulcerations detected

Neck: nodes are healthy – consistent, at the right place, and of the expected size. 

Cardiovascular

Heartbeat and pulse are normal, and patient does not report any pain or discomfort in the chest, or unexplained fatigue. 

Respiratory: lungs are healthy and working properly

Gastrointestinal: no digestive issues reported, or intolerance to specific foods in and before the current condition. 

Breast: no lump or inconsistent texture noted, or discomfort reported by the patient. 

Genitourinary

 Slight blood discharge seen during examination. Other parts of the reproductive and urinary systems appear to be healthy. 

Musculoskeletal: healthy, with no pain reported by patient, or abnormalities seen during physical examination. 

Neurological 

Healthy

Psychiatric

NO issues with stress or depression reported. Physical examination also reported no medical issues relevant with the symptoms presented.

Lab Tests: Prescribed laboratory examination suggested that the bleeding may be caused by issues with the hypothalamic-pituitary-ovarian systems, which are not yet mature.

Special Tests: None proffered. 

 Diagnosis 

 Differential Diagnoses: 

• excessive physical exercise
• hypothalamic-pituitary-ovarian immaturity
• inherited menorrhagia 

Diagnosis

 The patient is diagnosed as having immature hypothalamic-pituitary-ovarian systems. In particular, premature ovarian failure has led to the bleeding, since the patient spears to be ovulating, or has just passed the ovulation process. This is known to cause such bleeding as exhibited by the patient. 

Plan/Therapeutics

• Plan:  A more in-depth examination of the patient’s reproductive systems is needed, to have a more definitive answer for the bleeding. The patient also needs to cut back on her physical workload, so as to eliminate the chances that this is causing the bleeding. Further investigation of the family’s medical history is needed to eliminate the possibility of inherited conditions presenting in the patient. 
  • Medication: Hormonal IUD (Mirena), will reduce the bleeding and correct hormonal imbalances that are determined to be behind the bleeding. They will also reduce the chances of abnormally heavy menstrual flows, as a more definitive treatment regime is investigated. 
  • Non-medical treatments: None are suggested at the moment. 
  • Patient education- The patient has been educated on the possible causes of the bleeding. She has been asked to reduce her workload, and also have more frank discussions with her mother on family medical history. Inherited conditions can cause the illness. If the physician has this information, he will be able to offer better interventions. The patient has been given more material to learn more about her condition, and possible ways through which she could mitigate it without medical interventions (Podder et al, 2020). 

 Evaluation of patient encounter- The patient is reasonable and knowledgeable. She has not panicked, though she is worried about what this could mean for her health. She has read online about the condition, which has heightened her anxiety Apart from this; she is doing well, and is highly appreciative of the thoroughness of the medical examination to establish the cause of her condition. The patient is expected to stick to the medication prescribed, going by her willingness to solve the issue, and her trust of the services offered by the medical personnel at the health facility.