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(Solved) Kayla brings Lily in for a sports physical, needed prior to the initiation of school, because Lily would like to play volleyball.


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.

Allergies: None

Medications: None

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?

Please answer this in soap note format thank you

 


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