HEENT: Normocephalic, +PERRLA, TMs gray and visible ossicles; intact, moist mucous membranes; nares patent; oropharynx clear.
Neck: No lymphadenopathy.
Cardiovascular: Regular rate and rhythm; no murmur; femoral pulses equal.
Respiratory: Lungs clear bilaterally.
Breast: Tanner IV symmetrical.
Abdomen: Flat, soft, nontender, muscular.
Genitourinary: Tanner stage IV.
Musculoskeletal: Full range of motion ×4 extremities; no pain or swelling, back straight; muscular.
Neurologic: Cranial nerves II–XII grossly intact, steady gait and balance; reflexes +2 and equal.
CRITICAL THINKING
1 What are the top differential diagnoses in this case and why?___Eating disorder___Excessive exercise___Malnutrition___Malabsorption___Thyroid disorder___Anxiety___Female athlete triad
2 What are the diagnostic tests required in this case and why?__Urine pregnancy test___Glucose___Urinalysis___CBC with differential___Thyroid panel___Prolactin level___Electrolytes
3 What are the concerns at this point?
4 Should Roseanne’s mother be asked to leave the room at this time? Why or why not?
5 What is the plan of treatment?
6 What are the plans for referral and follow‐up care?
7 What health education should be provided to this patient?
8 What demographic characteristics might affect this case?
9 Are there any standardized guidelines that should be used to treat this case? If so, what are they?
10 If this patient was male (instead of female), how would that change management and/or treatment?
Case 5.3 Menstrual Cramps
By Vera Borkowski, MSN, APRN, FNP‐C
SUBJECTIVE
Khaleesi is a 16‐year‐old who comes to the school‐based health center (SBHC) after she just got her period in school. She is requesting a pad or tampon from SBHC because “I’m embarrassed … I soaked through my clothes.” Khaleesi says she usually misses “about 1 or 2 days each month because of my period.” While checking the patient into the electronic health system, it is noted her school absences are high. She reports she’s gotten her period since age 11, every month, but once she got it twice in one month. She uses 6 pads or tampons on the heaviest days, but her period usually only lasts about 5 days. She says her cramps, “aren’t too bad usually, but sometimes I will throw up when they are really bad.” She reports “I think my mom gives me Advil sometimes?,” but she does not use medication every period, and “it only helps sometimes.” Khaleesi denies any urinary frequency, urgency, dysuria, hematuria, vaginal discharge, pruritus, lesions, or lower abdominal pain other than “my normal cramps.”
Past medical history: Tonsillectomy and adenoidectomy around age 8; seasonal allergies.
Family history: Khaleesi’s mother and aunts with heavy periods.
Social history: Denies drug, alcohol, or vaping use. Denies any sexual activity (oral, anal, or vaginal) current or in past.
Medications: Zyrtec 10 mg only in springtime for allergies.
Allergies: NKDA, no food allergies.
OBJECTIVE
Vital signs: Height: 61 in; weight: 122 lbs; BP: 118/68; HR: 80; RR: 12; BMI: 23. Pain 5/10 on numeric scale, lower abdominal. Patient Health Questionnaire‐2 = 0 negative screening.
General: Pleasant, well developed, well nourished, in no acute distress.
Respiratory: CTA bilaterally, no wheezes, rales, or rhonchi.
Cardiac: RRR, S1 S2 normal with no murmurs, rubs, or gallops.
Breast: Tanner V symmetrical.
Abdomen: Bowel sounds present, abdomen soft, nontender, nondistended with no hepatosplenomegaly.
Genitourinary: Pubic hair; Tanner V normal female; + menses.
CRITICAL THINKING
1 What is the most likely differential diagnosis and why?___Dysmenorrhea___Endometriosis___Pelvic inflammatory disease (PID)___Urinary tract infection (UTI)___Appendicitis___Pregnancy—threatened abortion___Pregnancy—ectopic
2 Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Pelvic and transvaginal ultrasound___CBC with differential___CMP___Urine pregnancy test___Pelvic exam with cervical swab for GC/CT
3 What questions would you ask Khaleesi about her menstrual cycle?
4 What additional information/questions are needed?
5 What is the plan of treatment?
6 Are there other options?
7 Is it common for teen girls to miss school because of their periods?
8 When should she be seen for follow‐up?
9 What health education should be provided to this patient?
10 Are there technologies available to assist this patient in her care?
Case 5.4 Missed Periods
By Vera Borkowski, MSN, APRN, FNP‐C
SUBJECTIVE
Genevieve is a 17‐year‐old female who came to the clinic requesting a pregnancy test “because I haven’t gotten my period and it is 3 weeks late.” Genny reports that she normally gets her period every month and uses a period tracker, and is able to report her last period’s exact start date 55 days ago. She reports that her last period was of normal duration and flow. She says she had multiple occurrences of unprotected sex with her boyfriend of the same age in the past month, and has not taken any pregnancy tests at home. Per her chart and report, Genny has not previously been screened for sexually transmitted infections (STIs). She states, “We lost our virginity to each other a few months ago, so I don’t think he has any STIs.” The clinician asks her if she wants to get pregnant and Genny states, “Not really, but my boyfriend doesn’t like using condoms.” Genny has not told her family she is sexually active, and is requesting that this visit be confidential. She is not on any type of birth control, “because I’m afraid if I ask, my mom will know I’m having sex.”
Past medical history: Obesity.
Family history: No pertinent family history.
Social history: Denies substances, alcohol, or vaping use. Scores negative on PHQ‐2 screening. Reports only vaginal intercourse in a monogamous relationship. 1 sexual partner.
Medications: None.
Allergies: NKDA
OBJECTIVE