Patient Information: Ms. L., 15 y/o Hispanic Female. S. CC: Sports physical HPI: Lily needs sports physical prior to the initiation of school, because she wants to play volleyball. Lily had menarche at age 13 with 4 periods that year, but none since her 14th birthday. She is now 15 and ½ years old. 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”. Lily denies any concerning symptoms and she denies interest in contraception. Lily will be a sophomore. She expresses angst at starting a new school and leaving her friends for the recent move. She sleeps 7-8 hours per night. She denies current sexual activity upon questioning or use of drugs and alcohol. She is currently dating a local boy she recently met. Her mother remains present throughout the gathering of the history. Current Medications: …show more content…
General: 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: Sinus tachycardia, 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