## Case Analysis: Addressing Adolescent Health Concerns
### Subjective Data
**1. Additional Subjective Data to Obtain:**
To thoroughly assess the patient’s condition, additional subjective data is crucial. Important aspects to inquire about include:
– **History of Present Illness (HPI):** Details about the onset, duration, and characteristics of symptoms.
– **Diet and Eating Habits:** Understanding the patient’s daily dietary intake, eating patterns, and any recent changes in appetite or weight.
– **Mental Health:** Exploring any feelings of sadness, anxiety, stress, or changes in mood or behavior.
– **Family and Social History:** Information about family dynamics, support systems, and any recent life changes or stressors.
– **Menstrual History (for female adolescents):** Details about the menstrual cycle, including regularity, flow, and associated symptoms.
– **Physical Activity:** The patient’s level of physical activity, including frequency, type, and any recent changes.
– **Substance Use:** Inquiry about the use of substances like alcohol, tobacco, or drugs.
– **Sleep Patterns:** Information about sleep quality, duration, and any disturbances.
### Objective Findings
**2. Additional Objective Findings to Look For:**
To build a comprehensive understanding of the patient’s condition, the following objective findings should be considered:
– **Vital Signs:** Measurement of blood pressure, heart rate, respiratory rate, and temperature.
– **Weight and Height:** Documentation of current weight and height to calculate Body Mass Index (BMI).
– **General Appearance:** Observations of the patient’s overall appearance, including signs of distress, nutritional status, and grooming.
– **Skin Examination:** Checking for signs of dehydration, pallor, or any dermatological issues.
– **Cardiovascular Examination:** Assessment of heart sounds, rhythm, and peripheral pulses.
– **Respiratory Examination:** Evaluation of breath sounds and respiratory effort.
– **Abdominal Examination:** Checking for tenderness, masses, or organomegaly.
– **Neurological Examination:** Assessment of mental status, reflexes, and motor and sensory functions.
### Diagnostic Exams
**3. Diagnostic Exams to Order:**
Based on the initial presentation, the following diagnostic exams might be necessary:
– **Complete Blood Count (CBC):** To evaluate overall health and detect various disorders, such as anemia or infection.
– **Comprehensive Metabolic Panel (CMP):** To assess liver and kidney function, electrolyte levels, and glucose.
– **Thyroid Function Tests:** To check for thyroid abnormalities that could affect metabolism.
– **Urinalysis:** To detect urinary tract infections, kidney disease, and other metabolic conditions.
– **Electrocardiogram (ECG):** To assess heart function and detect any cardiac abnormalities.
– **Psychological Evaluation:** If mental health concerns are evident, a referral to a psychologist or psychiatrist for a detailed assessment might be necessary.
### Differential Diagnoses
**4. Differential Diagnoses Based on Presenting Symptoms:**
– **Anorexia Nervosa:** Characterized by an intense fear of gaining weight and a distorted body image, leading to severe restriction of food intake.
– **Depression:** Symptoms may include persistent sadness, loss of interest in activities, changes in appetite, and sleep disturbances.
– **Hyperthyroidism:** Symptoms include weight loss despite increased appetite, rapid heartbeat, sweating, and anxiety.
**5. Rationales for Differential Diagnoses:**
– **Anorexia Nervosa:** The combination of weight loss, restrictive eating habits, and possible psychological distress points to this diagnosis. The physical exam may reveal signs of malnutrition and bradycardia.
– **Depression:** The presence of mood changes, loss of interest in daily activities, and potential changes in weight and sleep patterns suggest depression. A mental health evaluation would provide further insight.
– **Hyperthyroidism:** Unexplained weight loss, increased appetite, and possible signs of tachycardia or tremors on physical examination could indicate hyperthyroidism. Thyroid function tests would be essential for diagnosis.
### Patient Teachings
**6. Teachings to Provide:**
Patient education should focus on the following areas:
– **Healthy Eating Habits:** Provide guidance on balanced nutrition, emphasizing the importance of regular meals and a variety of food groups.
– **Mental Health Awareness:** Educate the patient and their family about the signs and symptoms of mental health issues and the importance of seeking professional help.
– **Physical Activity:** Encourage regular physical activity that is enjoyable and suitable for the patient’s fitness level, promoting overall well-being.
– **Stress Management:** Teach techniques for managing stress, such as mindfulness, relaxation exercises, and healthy coping mechanisms.
– **Substance Use Avoidance:** Discuss the risks associated with substance use and promote healthy alternatives for stress relief and social interaction.
– **Follow-Up Care:** Emphasize the importance of regular follow-up appointments to monitor health and adjust treatment plans as necessary.
### References
Golden, N. H., Katzman, D. K., Kreipe, R. E., Stevens, S. L., Sawyer, S. M., Rees, J., … & Rome, E. S. (2015). Eating disorders in adolescents: Position paper of the Society for Adolescent Health and Medicine. Journal of Adolescent Health, 56(1), 121-125. https://doi.org/10.1016/j.jadohealth.2014.10.248
Linardon, J., Wade, T. D., de la Piedad Garcia, X., Brennan, L., & Franko, D. L. (2017). The efficacy of cognitive-behavioral therapy for eating disorders: A systematic review and meta-analysis. Journal of Consulting and Clinical Psychology, 85(11), 1080-1094. https://doi.org/10.1037/ccp0000245
Once you received your case number, answer the following questions:
1. What other subjective data would you obtain?
2. What other objective findings would you look for?
3. What diagnostic exams do you want to order?
4. Name 3 differential diagnoses based on this patient presenting symptoms?
5. Give rationales for your each differential diagnosis.
6. What teachings will you provide?
Submission Instructions:
Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.
image1.png
The post Case Analysis: Addressing Adolescent Health Concerns appeared first on Destiny Papers.
