I-HUMAN ELISA HENDERICK 2
SUBJECTIVE
CC: "Weight Loss."
HPI: Patient is a 16 y/o school age female with a PMH significant for social
anxiety and phobia related to perceptions of her weight; subjective feelings
of being overweight (BMI 15.7), but with a 20 lb weight loss over the last 6
months due to self-restriction of food, food preoccupation, with reported self
induced vomiting (2-3 x per week) with periods of binge eating, and use of
laxatives for constipation. Patient also endorses excessive exercise with
associated amenorrhea and recent metatarsal stress fracture of her left foot.
Lastly, patient endorses fatigue, and loss of interest in usual activities related
to internal family issues.
Psychiatric hx: Reports of social anxiety and phobia related to perceptions
of her weight. Medications: OTC Laxatives
Medical hx: Metatarsal stress fracture of her left foot (non-surgical - 8
weeks with walking boot)
Surgical hx: Denies
Allergies: Denies
Family hx: Parents divorced one year ago.
Social hx: 11th grade High School student, who lives with her Mon in a SFH.
She denies any toxic habits.
ROS:
Constitutional: Admits to weight loss. Denies fever, chills, rigors, night
sweats, recent illness.
HEENT: Denies visual changes, headaches, vertigo, hearing changes, ear
pain, sinus problems, difficulty swallowing.
Cardiovascular: Admits to x1 fainting episode. Denies chest pain, or
Palpitations.
Respiratory: Denies difficulty breathing, shortness of breath, wheezing,
difficulty catching breath, chronic cough, sputum production.