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Primary vs Secondary
History
16 year old female Patient concerns or questions: Amenorrhea and Headaches. 1) Loss of Period (r/o Secondary Amenorrhea) Menarche: ~11yo. LMP: over 4 months ago Cycles were very regular (started on the 7th or 14th every month), lasted 7 days, medium flow, never kept her home or affected daily life, no dizziness Has never had preceding ovulatory symptoms (abdominal pain, breast tenderness, mood changes) nor changes during the time of her period Has had increased exercise(playing JV soccer), continues poor eating habits
(rarely eats breakfast/lunch, occasionally eats dinner) Mildly more stress in her life, but fairly benign. This stems from starting school and having harder classes, though still doing well and her guardian believe this is being handled very well .
Continuing
2) Headaches Left sided. Occurring less frequently. Given a headache log calendar
No reported weight loss or weight gain over time. No change in pant size. Denies
however according to her growth chart she had been tracking on the 32% and then went up to 48% last visit (May 2012) and now back down to 35%.
SOCIAL HISTORY: Born in Mexico, Moved to Utah at young age. In DCSF custody ~10 months
Sexual History: No wanted Partners; Raped in current year Substance use: She denies smoking tobacco and using alcohol or illicit substances She is a Jr in high school; good performance and attendance Mood symptoms/suicidal ideation: Good mood, no SI, HI Increased stressors with school
Physical Exam
Vitals:
BP 111/74 | Pulse 60 | Temp 98.2 F (36.8 C) | Wt 51.7 kg ( 34%ile) C) | Ht 155cm (13%ile) | BMI 21
GEN: Alert, Active, NAD, normal color and normal perfusion HEENT: Scar over Left cheek otherwise Normocephalic and atraumatic; Red reflex present bilaterally, EOMI, pupils equal round and reactive to light and accommodation and fundi normal, Nares, Ears, Throat normal. Dentition normal. No parotid gland felt. NECK: supple, full range of motion, no masses and no lesions CHEST: Breasts normal appearing, (Tanner IV) , Clear to auscultation bilaterally, good aeration, normal respiratory rate and chest symmetrical CV: Regular rate and rhythm, PMI normal, regular rate, regular rhythm, no murmur, femoral pulses bilaterally and good peripheral pulses. ABD: soft, nontender, nondistended, no HSM, normal bowel sounds. No masses. No uteral fundus felt. SKELETAL: back straight, normal gait, no sacral dimple, upper extremities with full range of motion, lower extremities with full range of motion and no cyanosis, clubbing or edema in all 4 extremities SKIN: normal color, normal perfusion, no rash and no birthmarks. No acne. No hirsutism. NEURO: Cranial nerves II-XII intact, normal strength, normal tone, normal coordination, DTR 2+ and symmetric and normal behavior GU: deferred
Pregnancy
Endocrine
Hyperandrogenism (21-hydroxylase deficiency) Stress; Weight Loss (diet,exercise); Poor Nutrition Systemic illnesses (CELIAC)
Psych
GU
Anorexia/Bulemia PCOS
Heme/Onc
Toxins/Drugs
Prolactinoma Pituitary Adenoma, Craniopharyngioma (Sellar Tumors) Adrenal Tumor Ovarian Tumor Antipsychotics (cause hyperprolactinemia) Illicit Drug Use
What we sent
Urine Hcg: Neg
TSH: 1.91 Prolactin: 6.1
Primary Amenorrhea
delayed menarche
(defined as any one of the following:)
maturation.
Secondary amenorrhea
loss of period
(defined as all of the following:)
Cessation of previously normal menstruation Has a gynecological age of at least 24 mos Gynecological age-time in months since menarche Time in months is best indicator a normal pattern should have been established Has not menstruated for three or more cycles
Combination:
Physical or emotional stress (Functional production of GnRH produces low FSH and LH Female athletes less leptin in fat (helps trigger GnRH secretion)
lose pulsatile LH release because of reduced
energy
Remember
Secondary must have a regular cycle and have had period
for 24 months
Most common are derangements of the
hypothalamus and pituitary
most often related to emotional or physical stress Dont forget pregnancy and medications