Elisa Henderick I-Human case 16 year old, female recent weight loss
Patient Information: E.H., 16-year-old, Female, Caucasian
Subjective:
CC :” Recent weight loss reported by family”
EH. is a 16-year-old Caucasian female who presented to the clinic accompanied by her mother with a history of a 20-pound weight loss in the last 6 months and a 30- pound weight loss within the last year. E.H. has also reported as restricting her daily food intake and restricting her carbohydrates. She also states that she excessively exercises and wakes during the night to exercise. It is also reported that she binges and also purges her food. Associated symptoms include fatigue and anxiety related to how she visualizes herself and how others perceive her. Other related symptoms include amenorrhea for the last 4 months and the use of laxatives to assist with her weight loss with a mild disinterest in her daily activities. No other symptoms were reported, and no treatment has been priorly utilized.
Current Medications: None
Allergies: No allergies reported
Pertinent PMHx: Patient has been
in general good health. Medical,
surgical, obstetric, hospitalizations: 1 / 3
Had a metatarsal fracture 3 months ago and fainted in volleyball practice 1 week prior. No other hospitalizations, surgeries, ER visits, or specialist provider visits noted.
Vaccinations:
Immunizations up to date for her age.
Developmental: Cognitive stage: Formal Operational Stage (12 years of age and over)
With this stage of development beginning at 12 years of age and older, children can follow the form of a logical argument without the reference to its content.Also, during this time, children can develop the abilities to think about abstract concepts and also test hypothetical problems and develop solutions to these problems. Also, children „s concrete operations are carried out on things and formal operations are carried out on ideas. It is also understood that formal operational thought is entirely freed from physical perceptual constraints.
Psychosocial: Erikson‟s Stage 5 Identity vs. Role
Confusion (Age12 years - 18 years) 2 / 3
This stage occurs during adolescence or the ages of 12 years to 18 years. During this time, they transition from childhood to adulthood, and become more independent, look to the future in terms of career, develop relationships, and look to the future concerning families and housing. According to Erikson, adolescents may also feel uncomfortable about their bodies until they can adapt to the changes.It is also understood at this stage adolescents explore possibilities and begin to develop their own identities. They may also have an identity crisis or experiment with different lifestyles such as in work, education, or political activities.
Soc Hx:
Marital status/personal support system: dependent
adolescent
Housing: lives in a single-family home and splits time
between her divorced mother and father‟s houses with her sisters.
Occupation: high-school student
Substance use (tobacco, alcohol, other substances): none
Pertinent sexual history: sexually active; reports not having
intercourse for a year prior
Fam Hx:
Father: ;
hyperparathyroidis
m Mother: no
medical problems
Siblings: sisters;
healthy
- / 3