A.P. a 15 y.o. F who is an established patient last seen 9 months ago for evaluation of depression but here today for 15 y.o. well-child checkup. Mother also present at well-child visit. Sh

C.C. 15 y.o. well child visit
HPI: A.P. a 15 y.o. F who is an established patient last seen 9 months ago for evaluation of depression
but here today for 15 y.o. well-child checkup. Mother also present at well-child visit. She denies any
recent concerns/complaints. Feels well on the bupropion and continues to see her counselor weekly.
Reports no depressive, suicidal symptoms. She is doing well in 10th grade attending cyber school, which
allows her to attend dance classes during the day. She reports menses is irregular. She eats a healthy
diet for dance, mostly lean protein and vegetables. She looks down and states “I don’t have time for
that now.” Mother agreed. After review of immunizations, it was noted she has yet to receive HPV
vaccine. When approached the topic, mother is against the vaccine. States “she is going to think it is
okay to have sex…. last time I was here you offered it to my son, who can’t even get cervical cancer. ”

PMH: Depression, Menarche 14 y.o.
PSH: None
Allergies: Denies any allergies to food, seasonal, medicine or latex
Medications: Bupropion 100 mg PO every morning
Social history: AP is a tenth-grade student that actively participates in dance. Attends cyber school. Has
a 17 y.o. brother who attends public school and is in the 12th grade. AP alternatives between both
parents’ households throughout the week. Denies any history of recreational drugs, tobacco or alcohol
use. Denies consumption of caffeinated beverages. She states she is virgin and has no interest in boys.
AP attends a Catholic affiliated church several times a week with her mother. Her hobbies consist of
reading books, drawing and dance. Per her mother she excels academically. Additionally, AP verbalizes
future plans of going to NYC for professional ballet.
Family history: AP’s father is alive and well with no history of medical problems. Her mother has a PMH
of HTN. Brother also suffers from depression and anxiety. AP’s maternal grandmother died at 61 due to
complications of breast cancer. Information is not available regarding paternal grandparents.
Health Maintenance/Promotion:

ROS:
General: Patient denies fatigue, fever, chills, malaise, night sweats, unexplained weight loss or weight
gain, loss of appetite, or difficulty sleeping.
Skin: Denies concerns.
HEENT: Patient denies vertigo, headaches, sinus problems, epistaxis, hoarseness, dental problems, oral
lesions, hearing loss or changes, nasal congestion. Patient denies blurred vision, difficulty focusing,
ocular pain, diplopia, scotoma, peripheral visual changes, and dry eyes. Patient does not wear glasses or
contact lenses. Date of last eye exam was June of this year.
CV: Patient states she does exercises often. Patient denies any history of heart murmur, chest pain,
palpitations, dyspnea, activity intolerance, varicose veins, and edema.
Lungs: Patient denies cough, SOB on exertion, difficulty breathing, wheezing, pain on inspiration. GI:
Patient denies dysphagia, reflux, pyrosis, loss of appetite, bloating, diarrhea, constipation, hematemesis,
epigastric pain, hematochezia, change in bowel habits, food intolerance, flatulence, hemorrhoids. No
rectocele, bowel incontinence or rectal bleeding.
GU: Denies dysuria, disease of the urinary tract, hematuria, incontinence or pain. Pt is not sexually active
and denies any sexually transmitted diseases.
MSK: Denies limited range of motion in all extremities, joints, spine. Denies injury, deformity, swelling.
Neuro: Denies numbness, tingling, weakness, dizziness or confusion.
Endo: Patient denies cold or heat intolerance, polydipsia, polyphagia, polyuria, changes in skin, hair or
nail texture, unexplained change in weight, changes in facial or body hair.
Psych: Denies suicidal ideation or thought. Believes her depression is well controlled.

Objective:
PE: AP is alert and oriented to person, place, time, and situation. She appears well groomed and
appropriately dressed for this visit. She appears well nourished. She is sitting upright in a chair, and she
does not seem to be in acute discomfort. She exhibits poor eye contact and appears quiet. Her parents
came to this visit with her.
VS: BP 99/68, HR 72, Temp 97.2 (orally), Respirations 16, O2 saturation 100% on room air. Weight 112
pounds. Height 5′ 7″ (67 inches), BMI 17.5 index.
Skin: Warm, pink and dry. No visible scars, ecchymosis or trauma. Thin frame.
HEENT: Head: Skull round with symmetrical protuberances, nontender upon palpation, hair evenly
distribution, and scalp clean and free of lesions. Eyes Sclera white. Conjunctivae pink. Pupils are PERRL, 3
mm bilaterally. Extraocular movements intact. Ears: external appearance normal-no lesions, redness, or
swelling; on otoscopic exam tympanic membranes clear. Hearing is intact. Nose: appearance of nose
normal with no mucous, inflammation or lesions present. Nares patent. Septum is midline. Mouth: pink,
moist mucous membranes. No missing or decayed teeth. Throat: no inflammation or lesions present.
Tonsils- present
Neck: Supple, no JVD, carotids 2+ without bruit, full range of motion, trachea midline and mobile,
thyroid not enlarged or nodular, no lymphadenopathy
CV: S1, S2. Regular rate and rhythm, no murmurs, gallops, or rubs. Carotid Arteries: normal pulses
bilaterally, no bruits present. Pedal Pulses: 2+ bilaterally. Extremities: no cyanosis, clubbing, or edema,
less than 2 second refill noted
Lungs: Lungs are clear to auscultation, Respirations are unlabored, breath sounds are equal and
symmetrical chest wall expansion noted. Chest: symmetric, tanner stage 3.
Abd: Soft, flat, nontender without masses or hepatosplenomegaly. Bowel sounds active. No bruits
GU: No costovertebral angle tenderness. Negative flank pain. No cystocele. No lymphadenopathy. Gyn:
Tanner stage 3. Labia majora/minora intact. MSK: Normal ROM and strength. No deformity noted
Neuro: Grossly alert and oriented x3, communication ability within normal limits, attention and
concentration normal. Normal sensory, and motor function. No focal deficits.
PV: No clubbing, cyanosis, edema noted. 2+ radial and pedal pulses bilaterally. Nailbed pink with
capillary refill brisk and less than 3 sec.
Psych: Judgment and insight intact. Pleasant and cooperative.
Instructions:
Please evaluate the subjective and objective information provided to you in the file below.
The first part of the discussion board is to identify all pertinent positive and negative information.
What other questions may you want to ask the patient?
How will you address these findings?
Now create a plan utilizing clinical practice guidelines for the priority diagnosis, as well as expected health promotion and expected anticipatory guidance.
Finally, how will you address the mother and her concerns.
Be sure to include APA in-text citations and provide full reference citation at the end of the discussion.

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