CC
Rose is a 16-year-old female here today with her mother to talk about several issues, including bulimia.
HPI
The patient tells me she is bulimic. She says that she has been binging and purging since the beginning of August. She remembers doing something similar in the spring of 2014, but says by summer was able to stop on her own and did not seek therapy or mention it any physician. She found initially what she was doing was over eating. Because of that, she forced herself to vomit because she was feeling too full. She says now and mom agrees that if she eats anything, she wants to throw up after, even if it is something small. The patient reports that this is becoming less and less. She had time yesterday where she did not purge after eating and she has not had any episodes today. She is really working to try to stop this on her own. She says her …show more content…
She currently with a long-time boyfriend that she does not use condoms with it. She admits that she had other partners while with her boyfriend. They discussed it and would like STD testing. She is having absolutely no symptoms at this time, including any pain in the vaginal area or the pelvic area, no vaginal discharge. No urinary symptoms. She was tested for Chlamydia and gonorrhea at her physical in April.
Medications
Fluoxetine 30 mg daily, birth control pill, Concerta 20 mg daily.
Social History
She does use tobacco. She is smoking five cigarettes a day, down from a pack and a half over the summer. Alcohol, she drinks beer on the weekends. She denies any illicit drug use currently or in the past.
O
Vital Signs
Temperature: 98.6. BP: 110/70. HR: Initially checked by the medical assistant at 120. Recheck at the end of visit 82. R: 14. W: 105.
General
A well-developed, well-nourished female seated comfortably in the exam room. She does have good eye contact, at times. Does answer questions when addressed. Alert and oriented in the office
Rose is a 16-year-old female here today with her mother to talk about several issues, including bulimia.
HPI
The patient tells me she is bulimic. She says that she has been binging and purging since the beginning of August. She remembers doing something similar in the spring of 2014, but says by summer was able to stop on her own and did not seek therapy or mention it any physician. She found initially what she was doing was over eating. Because of that, she forced herself to vomit because she was feeling too full. She says now and mom agrees that if she eats anything, she wants to throw up after, even if it is something small. The patient reports that this is becoming less and less. She had time yesterday where she did not purge after eating and she has not had any episodes today. She is really working to try to stop this on her own. She says her …show more content…
She currently with a long-time boyfriend that she does not use condoms with it. She admits that she had other partners while with her boyfriend. They discussed it and would like STD testing. She is having absolutely no symptoms at this time, including any pain in the vaginal area or the pelvic area, no vaginal discharge. No urinary symptoms. She was tested for Chlamydia and gonorrhea at her physical in April.
Medications
Fluoxetine 30 mg daily, birth control pill, Concerta 20 mg daily.
Social History
She does use tobacco. She is smoking five cigarettes a day, down from a pack and a half over the summer. Alcohol, she drinks beer on the weekends. She denies any illicit drug use currently or in the past.
O
Vital Signs
Temperature: 98.6. BP: 110/70. HR: Initially checked by the medical assistant at 120. Recheck at the end of visit 82. R: 14. W: 105.
General
A well-developed, well-nourished female seated comfortably in the exam room. She does have good eye contact, at times. Does answer questions when addressed. Alert and oriented in the office