NR602 Week 2 1 Week 2 PBL Case Study Discussion

12 August 2024

NR602 Week 2.1

Week 2: PBL Case Study Discussion: Assessment of the Adolescent Part One

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Part One

“Kayla brings LF in for a sports physical, needed prior to the initiation of school, because LF would like to play volleyball. Mother is also concerned because LF had menarche at age 13 with 4 periods that year, but none since her 14th birthday. She is now 15 and ½ years old. LF 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 reports she would also like to begin LF 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. LF denies any concerning symptoms and she denies interest in contraception.

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 6 lb 4 oz. She experienced a right radial fracture at age 8 and tonsillectomy and adenoidectomy at age 9.

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?

Questions:

When did she start having these concerns? How is she feeling about her parent’s separation, and moving into her grandparent’s home? Has she made any friends in this new area? How often are these concerns bothering her? Can she describe any physical or psychological symptoms that occur? Does anything make her concerns worse? Does anything make her concerns better? Has she done anything to relieve her concerns? And does it help? Has she participated in sports before? What kind? Did she have any problems playing sports, or injuries or overuse symptoms related to playing sports?

1. What is one important item you learned about gathering a history on an adolescent?

When gathering a history from an adolescent, it’s essential to create an environment of trust and confidentiality. Adolescents may be hesitant to share sensitive information if a parent is present, especially regarding topics like sexual activity, mental health, and substance use. Establishing a rapport and ensuring the adolescent that certain aspects of their history will remain confidential unless there is a risk of harm to themselves or others is crucial.

2. For a sports physical, did you pick up any ‘red flags’ in the historical data?

Yes, there are a few potential red flags in the historical data:

  • Amenorrhea: LF had menarche at age 13 but has not had a period since her 14th birthday, which may indicate secondary amenorrhea. This warrants further investigation to rule out underlying conditions such as hormonal imbalances, stress, eating disorders, or excessive physical activity.
  • Psychosocial Stress: LF expresses angst about starting a new school and leaving her friends, which could indicate emotional or psychological stress. This stress may also be contributing to her menstrual irregularities.
  • Lack of Immunizations: The mother mentioned that LF hasn’t had any immunizations since kindergarten. It’s important to update her immunizations, especially considering her participation in sports.

3. What information should always be gathered on an adolescent that you have not previously seen?

When assessing an adolescent, it’s important to gather comprehensive information, including:

  • Social History: Details about the adolescent’s relationships, social interactions, and living situation. This includes assessing for stressors related to school, friendships, and family dynamics.
  • Mental Health History: Screening for signs of depression, anxiety, eating disorders, or other mental health concerns. Adolescents often face significant emotional changes, and early detection of mental health issues is crucial.
  • Sexual History: Even if the adolescent denies current sexual activity, it’s important to discuss sexual health, contraception, and safe sex practices.
  • Substance Use: Inquire about the use of tobacco, alcohol, and drugs, even if the adolescent denies current use.
  • Physical Activity and Nutrition: Assess the level of physical activity, dietary habits, and any history of eating disorders, especially if there are concerns like amenorrhea.

4. What makes a sports physical unique from other exams?

A sports physical is focused on evaluating an adolescent’s physical ability to safely participate in sports. It involves a detailed assessment of the musculoskeletal system, cardiovascular health, respiratory function, and overall physical fitness. Additionally, the sports physical considers any history of injuries or conditions that could be exacerbated by physical activity, such as asthma or joint issues. The goal is to ensure the adolescent is physically prepared and to identify any conditions that may require further evaluation or intervention.

5. What are your differential diagnoses?

Given LF’s history, the following differential diagnoses should be considered:

  • Secondary Amenorrhea: Possible causes include stress, polycystic ovary syndrome (PCOS), thyroid dysfunction, or eating disorders.
  • Psychosocial Stress: The stress of moving, starting a new school, and leaving friends could be impacting LF’s overall health, including her menstrual cycle.
  • Delayed Puberty: Although less likely given her history of menarche, it’s important to rule out any endocrine disorders.
  • Nutritional Deficiency: Lack of proper nutrition or an undiagnosed eating disorder could be contributing to her amenorrhea and overall health concerns.

6. What further history should be gathered today and why?

Further history should include:

  • Detailed Menstrual History: Inquire about the nature of her periods before they stopped (e.g., regularity, flow, associated symptoms).
  • Diet and Exercise Patterns: Assess her diet, weight changes, exercise routines, and any signs of disordered eating.
  • Stress and Mental Health: Explore her feelings about the move, new school, and any signs of anxiety or depression. Understand how she is coping with these changes.
  • Sexual History: Even though she denies current sexual activity, it’s important to discuss her understanding of contraception, safe sex, and the implications of her mother’s request for birth control.
  • Immunization Records: Verify and update her immunization status to ensure she is protected, especially before participating in sports.