The Adolescent
Case 5.3 Weight Loss
144 The Adolescent
OBJECTIVE
General: Thin teen dressed in multiple layers, interactive, initially shy and now more talkative.
Vital s igns: Height: 63 inches; weight: 100 pounds; BMI: 17.7 (sixth percentile); BP: 90/50; HR:56;
RR: 12.
Skin: Cool, mottled, without acne; some white, downy hair on upper back and arms.
HEENT : Normocephalic, + PERRLA, TMs gray pearly, + LR, moist and intact mucous membranes;
nose patent without rhinorrhea; oropharynx clear.
Neck: No lymphadenopathy.
Cardiovascular: RRR with clear S1 and S2; no murmur; femoral pulses are equal and + 2.
Respiratory: Lungs CTA.
Breast: Tanner IV symmetrical.
Abdomen: Soft, fl at, nontender; no HSM.
Genitourinary: Pubic hair; Tanner IV normal female; mucosa pale and pink; no lymphadenopathy, discharge, or odor.
Musculoskeletal: Back straight; FROM × 4 extremities.
Neurologic: Cranial nerves II – XII grossly intact; steady gait and balance; alert and interactive; refl exes + 2 and equal.
CRITICAL THINKING
Which diagnostic or imaging studies should be considered to assist with or confi rm the diagnosis?
___Urine pregnancy test ___Glucose
___Urinalysis ___CBC ___MCV
___Erythrocyte sedimentation rate ___Electrolytes
___Thyroid function tests
___Thyroid stimulating hormone ___Prolactin
___Testosterone panel
___Sex hormone binding globulin ___Gonorrhea and chlamydia ___HIV
What is the most likely differential diagnosis and why?
___Eating disorder ___Excessive exercise ___Malnutrition ___Malabsorption ___Hyperthyroid ___Depression
Weight Loss 145
Should Susie ’ s mother be in the room or asked to leave? Explain your rationale.
Based on the information you have gathered at this point, are there any additional questions you have for Susie or her mother?
Is her menstrual history a concern or normal given the age of menarche and her current age?
You ask Susie if she is aware of why her mother brought her to the visit today; and she replies, “ She is just making a lot out of me losing some weight. ” How would you reply?
Are there any additional exam fi ndings that are necessary at this point?
Based on the information gathered in the history and physical examination, what will you discuss with Susie and her mother?
When would you like to see her for follow up?
Can she be managed on an outpatient basis?
RESOLUTION
Diagnostic t ests: All of the following tests should be done: Urine pregnancy test, glucose, urinalysis, CBC, MCV, erythrocyte sedimentation rate, electrolytes, thyroid function tests, thyroid stimulating hormone, prolactin, testosterone panel, and sex hormone binding globulin.
Consider urine testing for gonorrhea and chlamydia, and HIV counseling and testing.
What is the most likely differential diagnosis and why?
There are several possible differential diagnoses. The primary diagnosis depends on responses to further questions that should be asked in the history and on the results of the lab work.
Should Susie ’ s mother be in the room or asked to leave? Explain your rationale.
Susie ’ s mother should be asked to leave the room after you have gathered suffi cient history. Susie may have questions or information for you that she is not comfortable discussing in front of her mother.
Based on the information you have gathered at this point, are there any additional questions you have for Susie or her mother?
• “ When did your weight become a concern? What was her weight at her last physical exam? ” • “ You play soccer. Tell me about that. Is it any different this season than last? Has anything
changed? Do you enjoy playing? ”
• “ How are you doing in school? Do you like it? What are your favorite and least favorite subjects? ”
• “ Do you have friends? Do they all play soccer, too? ”
• “ Tell me about your periods. How old were you when you got your fi rst period? Do you get it every month? Do you ever miss periods? ”
• Questions regarding sexual activity should also be explored without the mother present. “ Have you been or are you currently sexually active? ”
• “ Are you taking any medications? Supplements? Vitamins? Herbal supplements? ”
• Do you ever feel sad, depressed, or anxious? Do you have diffi culty sleeping? Do you have dif- fi culty concentrating? Do you cry easily? ”
• “ Do you have headaches, visual changes, constipation or diarrhea, abdominal pain, dry skin, excessive fatigue? ”
Is her menstrual history a concern or normal given the age of menarche and her current age?
Menstrual cycles can be irregular for several years following menarche because of anovulation.
However, other causes of secondary amenorrhea need to be considered. The most common causes of
146 The Adolescent
secondary amenorrhea, other than weight changes, in an adolescent are pregnancy, side effects of contraception, polycystic ovary syndrome, stress, hypothyroidism, and prolactinoma.
You ask Susie if she is aware of why her mother brought her to the visit today; and she replies, “ She is just making a lot out of me losing some weight. ” How would you reply?
• “ Tell me more about that. Have you lost weight? ”
• “ Your mother said that you run. How many miles per day or per week? ” • “ What other activities do you do? ”
• “ Tell me about your family. Do you get along with everyone? Have there been any changes at home?
• “ Describe what your typical breakfast, lunch, and dinner would consist of? ” • “ Do you each snacks? If so, what? ”
• “ Do you ever vomit after eating or take laxatives? ”
• “ Do you eat in private when no one else is around? If so, tell me about that. ” Are there any additional exam fi ndings that are necessary at this point?
• Temperature
• Percentiles for height, weight, and BMI; plot these on a growth curve.
• Pregnancy test • Urine dip
• Visual fi elds; fundoscopic exam • Parotid gland
• Tooth enamel erosion • Thyroid
• Russell sign
• Palms for carotenemia
• Skin fold thickness and mid - upper arm circumference
Based on the information gathered in the history and physical examination, what will you discuss with Susie and her mother?
Discuss the cause of Susie ’ s weight loss. It is likely the result of an increase in exercise and decrease in caloric intake. Her physical examination was normal. However, she is at the sixth percentile for weight . Laboratory tests will be ordered today to confi rm that no other medical problems exist.
Provide education on improving daily nutrition, decreasing daily amount of exercise, importance of maximizing bone density during adolescence, and calcium/vitamin D supplementation. A diary or journal can be started to record current weight, diet, and amount/type of exercise.
When would you like to see her for follow up?
Susie ’ s weight, exercise, and eating patterns need to be monitored closely. Susie should return to the clinic in a week for laboratory results, weight check, and further counseling.
Can she be managed on an outpatient basis?
Yes. She is physiologically stable and has family support.
REFERENCES AND RESOURCES
Hacker , K. A. , Myagmarjav , E. , Harris , V. , Suglia , S. F. , Weidner , D. , & Link , D. ( 2006 ). Mental health screening in pediatric practice: Factors related to positive screens and the contribution of parental/personal concern . Pediatrics , 18 ( 5 ), 1896 – 1906 . Retrieved from http://www.pediatrics.org/cgi/content/full/118/5/1896 Neinstein , L. , Gordon , C. M. , Katzman , D. K. , Rosen , D. S. , & Woods , E. ( 2008 ). Adolescent health care: A practical
guide ( 5th ed. ). Philadelphia : Lippincott Williams & Wilkins .