Study Document
Treatment of Pubertal Disorders Essay
Pages:2 (495 words)
Sources:2
Subject:Health
Topic:Pubic Hair
Document Type:Essay
Document:#29816609
Soap Note
Patient: A 12-year-old patient visiting the physician for well-child examination.
Source and Reliability: Mother and father, both reliable sources.
Subjective (S):
Patient Case, Age and Clinical Setting: 12 years patient visiting a physician.
Chief Complaint: Few minor illnesses over the past 2 years.
HPI: The patient last visited the physician for a well-child examination 2 years ago. He has a few minor illnesses since then. He is currently in the puberty stage of development.
Past Medical History: Few minor illnesses.
Family History: None
Social History: Patient lives with his mother and father.
Risk Factors: Sexual maturation, pubertal growth spurt, and abnormal pubertal development.
ROS: Premature adrenarche.
Objective (O):
VS: BP - 115/70, Temp - 98, weight - 80 pounds, height – 59 inches, HR – 90.
Physical Exam:
· The patient is alert but does not fully understand changes in his body.
· He started developing some underarm and pubic hair more than 2 years ago.
· He exhibits psychological disturbances linked to the changes in his body.
Diagnostic Test Result: Premature adrenarche. He was diagnosed with this condition on January 27, 2019 because of signs of abnormal pubertal change.
Assessment (A):
Significant Health Problem: The patient’s major health issue or problem is premature adrenarche that is characterized by development of underarm and pubic hair at an early age. Based on the ICD-10 Codes, his condition falls under E80.9, which is used for diagnosis of disorders of puberty (ICD10 Data, 2018).
Key Differential Diagnoses:
· Precocious puberty (E30.1): The patient could be diagnosed with this condition because he/she started developing pubic and underarm hair (Oberfield, Sopher & Gerken, 2011). The development of these changes in his…
Sample Source(s) Used
References
ICD10 Data. (2018). 2020 ICD-10-CM Diagnosis Code E30.1. Retrieved January 22, 2020, from https://www.icd10data.com/ICD10CM/Codes/E00-E89/E20-E35/E30-/E30.1
Oberfield, S.E., Sopher, A.B. & Gerken, A.T. (2011, June). Approach to the Girl with Early Onset of Pubic Hair. The Journal of Clinical Endocrinology & Metabolism, 96(6), 1610-1622.
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