Pediatric Case Write Up

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. PMH: 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 Medications: 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. ROS: General: +weight loss, +tiredness & fatigue Skin: no rashes, discolorations, acne, or increased hair growth HEENT: no headaches, nasal congestion or sinus problems; no eye or ear pain or discharge, no lumps in the neck Respiratory: negative for sob/ difficulty breathing Cardiovascular: negative for palpitations or chest pain.

Gastrointestinal: negative for constipation, diarrhea, or any changes in the color, consistency, frequency, or smell of the stool. No bright red blood in stool Genitourinary: Negative for dysuria, increased frequency, increased urgency, hematuria, polyuria, history of kidney stones Endocrine: negative for increased thirst, polyphagia, feelings of excessive cold or warmth Musculoskeletal: No pain, swelling, erythema of extremities or joints Neurologic: no dizziness, negative for episodes of seizures, loss of consciousness, no weakness in extremities Allergic/Immunologic/Lymphatic: No reaction to drugs, food, or insects.

No swelling of lymph nodes, no recurrent infections PE Vitals: T: 38 BP:119/76 HR: 89, RR: 15 Growth: Height: 5’7″, Weight 121 pounds (25-50%) BMI 18. 9 General: Thin, well developed, undernourished, adolescent girl in NAD, appears her stated age Skin: dry, warm, normal for age, good turgor, no rashes or jaundice, no acne, normal hair distribution Head: normocephalic atraumatic.

Eyes: EOMI, PERRL, sclera anicteric, pink conjunctiva and moist ENT: Tympanic membrane nonerythematous, mucous membranes moist, normal oropharynx w/o erythema or exudates, no ulcerations Neck: supple, no Lymphadenopathy, no stiffness, no masses or erythema Cardiac: Regular rate and rhythm, normal S1S2, no murmurs, rubs or gallops Respiratory: clear to ausc bilaterally, good air entry, no wheezing, no rales, crackles or rhonchi Abdomen: soft, NT, ND, +BS, no organomegaly, no discolorations, no masses, Musculoskeletal: no erythema or discoloration, no gross deformities Extremities: no cyanosis, no clubbing, no edema.

Neuro: Alert and Oriented x 3 Labs: WBC 4. 8, RBC 4. 0, Hb 11. 3, Hct 33, MCV 79, RDW 17, plt 222 Urine Pregnancy: Negative Assessment: 17 yo F with PMH of depression and anorexia nervosa presents with a missed period. The patient’s presentation and labs make the most likely diagnosis amenorrhea due to Oral contraceptive cessation. When OCPs are discontinued, it may take 3-6 months to resume ovulation. Her labs also show a mild normocytic anemia most likely related to undernourishment and subsequent weight loss.

Anorexia can be ruled out since Her BMI of 18. 9 is considered normal, and she denies binging, purging, laxative use and states that she has good body image. She has only had one month of amenorrhea, and three consecutive months would be required to consider anorexia. She does admit to a 10 pound weight loss in the past 6 weeks, but more of a drastic weight loss would usually be needed to induce amenorrhea. Differentials:

Amenorrhea secondary to OCP cessation: When OCPs are discontinued, it may take 3-6 months to resume ovulation and menstruation. The fact that this patient admitted to discontinuing the pill a month ago suggests this as the most likely diagnosis, especially since the urine pregnancy test came back negative. Pregnancy: The patient has been sexually active and has not been on any form of birth control for the past one month. Her urine pregnancy test came back negative, however there is a slight possibility that this is a false negative.

Research presented at the Scientific Assembly of the American College of Emergency Physicians revealed that almost six percent of negative urine pregnancy tests can be false negative. Anorexia/weight loss induced amenorrhea: This patient has a past psychiatric history of Anorexia nervosa diagnosed two years ago. In order to be given the diagnosis of anorexia, the patient must be less than 15% normal body weight which is not the case for this patient. Also the patient must have a poor sense of body image along with at least three consecutive months of amenorrhea.

While this patient has lost about 10 pounds in the past 6 weeks, she admits that this was unintentional and denies symptoms of anorexia. Two more months of amenorrhea would also be needed to consider this diagnosis. Antidepressant induced amenorrhea : The patient stated that she is on antidepressants for the past two years. One of the side effects of Prozac (fluoxetine) is an elevated prolactin level. There have been instances where this increased prolactin has caused women to miss their period, however, a prolactin level would be needed in this patient.

There were no symptoms, other than a missed period, of hyperprolactinemia, such as galactorrhea, loss of libido and vaginal dryness, but a prolactin level would still be needed to rule out. Polycystic Ovarian Syndrome: PCOS is a common cause of amenorrhea, however this patient denies any family history or medical history of ovarian diseases. Weight gain is usually associated with PCOS and this patient has weight loss. There was no extra hair on the face and body and no acne, therefore this diagnosis is highly unlikely.

Thyroid disease (Hyper/Hypothyroidism): Hypothyroidism can cause amenorrhea, and this patient does have a history of depression, and current feelings of tiredness and fatigue, however hypothyroidism is more associated with weight gain which this patient does not have. Hyperthyroidism can also cause a patient to miss their period if the hyperthyroidism is due to increased release of TRH by the hypothalamus. The patient admits to unintentional weight loss, but denies other symptoms of hyperthyroidism such as anxiety, increased sweating, palpitations, and heat intolerance.

Plan: – Amenorrhea 3-6 months may be needed after OCP cessation to resume normal periods repeat urine pregnancy test or do a Blood test for HCG which has more accuracy Prolactin Level TSH and free T4 level – normocytic anemia Iron tablets – Weight loss Arrange for patient to see a dietician to educate her about healthy eating habits – Plans to become Pregnant Arrange for the patient to see a social worker to discuss the patient’s plans, and possibly counseling to discuss the consequences of teenage pregnancy.

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Chief Complaint: The patient presents in the emergency room this morning, complaining of lower abdominal pain. History of Present Illness: The patient states that she has been having vaginal bleeding more like spotting over the past month. She denies the …

HISTORY OF PRESENT ILLNESS: The patient states that she has been having some vaginal bleeding, more like spotting over the past month. She denies the chance of pregnancy although she states that she is sexually active and using no birth …

HISTORY OF PRESENT ILLNESS: The patient states that she has been having vaginal bleeding, more like spotting, over the past month. She denies the chance of pregnancy, although she states that she is sexually active and using no birth control. …

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