Ms. Monroe Adolescent Sports Evaluation shadow health

Vitals:
– Current Visit:
– Height: 157.4 cm
– Weight: 49.9 kg
– BMI: 20
– Temperature (<38° C): 36.6° C
– Heart Rate (60-100): 78
– Respiratory Rate (12-20): 16
– Blood Pressure: 112/70

Table of Contents

Documentation / Electronic Health Record

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Subjective:
Ms. Monroe, a 13-year-old female, is seeking a preparticipation evaluation for soccer. No current medical problems, a history of tonsillectomy, and no prescription medications. Takes a multivitamin and apple cider vinegar. Follows a Mediterranean diet, avoids sweets, processed foods, and white carbs. Skips lunch 1-2 times a week. Plays soccer on weekends. No family history of genetic heart problems. Review of Systems indicates no significant issues.

Objective:
– Vitals:
– Height: 62 in.
– Weight: 49.9 kg
– BMI: 20
– Blood Pressure: 112/70
– Temperature: 36.6°C
– Heart Rate: 78/min
– Respiratory Rate: 16 breaths/min
– General:
– Well-appearing 13-year-old in no acute distress.
– HEENT:
– Symmetrical head, eyes PERRLA, EOM intact, full neck range of motion.
– Respiratory:
– Symmetrical chest rise and fall, clear lungs.
– CV:
– Regular rate and rhythm, S1S2 present, no murmurs, equal pulses.
– Abd:
– No bruit in abdominal aorta.
– MSK:
– Symmetrical bilateral extremities, full range of motion.
– Skin:
– Warm, no rash or lesions.
– Neuro:
– Alert and oriented x3, intact balance, steady gait.

Assessment:
– Pre-participation sports physical
– Inappropriate diet and eating habits

Conditions of the Hematologic System Anita Douglas Shadow Health

Plan:
1. Preparticipation sports physical: Clear to participate in sports.
2. Inappropriate diet and eating habits:
– Educate on healthy nutrition.
– Discuss strategies for reducing shame around eating and weight.
– Educate on detecting problematic eating behaviors.
– Follow up in 4 weeks for reevaluation.

Expanded Plan:
1. Preparticipation sports physical:
– Clear to participate in sports.

2. Inappropriate diet and eating habits:
– Provide education on healthy nutrition and its impact on the body.
– Discuss potential life-threatening problems due to improper nutrition.
– Emphasize a healthy diet with three meals a day and appropriate snacks, especially when exercising.
– Discuss strategies for reducing shame around eating, weight, and self-perception.
– Introduce coping mechanisms for self-esteem and body image, including journaling, support groups, relaxation techniques, positive self-talk, and affirmations.
– Advocate for limiting media intake, avoiding shows on weight loss or dieting.
– Educate on identifying problematic eating behaviors.

Anticipatory Guidance:
– Safety: Review sports safety measures, including the female athlete triad, injury prevention, sunscreen use, and sun protection.
– Diet and Nutritional Supplements: Provide guidance on a healthy diet and discuss the role of nutritional supplements.

Follow-up:
– Return to the clinic in 4 weeks to reevaluate nutrition and eating habits.

This comprehensive documentation outlines Ms. Monroe’s current health status, subjective concerns, and objective findings, paving the way for an informed and personalized plan to address her preparticipation needs and nutritional habits.

Adolescent Sports Evaluation Samantha Monroe shadow health Transcript