Gathering A History On An Adolescent

Case Study Discussion – Part 1

What is one important item you learned about gathering a history on an adolescent? For a sports physical?
Did you pick up any ‘red flags’ in the historical data?

What information should always be gathered on an adolescent that you have not previously seen?

………. makes a sports physical unique from other exams?

What are your differential diagnoses?

What further history should be gathered today and why?

Case Study Discussion – Part 2

Physical Examination of Lily:

V/S: Height- 160 cm, Weight- 45 kg, B/P 114/60, HR 90, RR 16, T 98.7, SpO2 99%

Awake, alert, oriented, cooperative. Difficulty with eye contact. Answers questions in short 1-2 word answers. HEENT: Head is normocephalic

Case Study Discussion – Part 3

Written summation of case in SOAP format.

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