Michelle Kennedy

MN552 UNIT 10 LAB 3

SOAP NOTE FOR CHILDHOOD OBESITY

SUBJECTIVE:

CHIEF COMPLAINT: Weight gain

HISTORY OF PRESENT ILLNESS: This is a 12-year old adolescent who presents in the office today with
concerns over a recent weight gain, acne, an increase of facial hair, and darkening of skin on the neck
and axillae. She is a straight A student with an increased stress level due to a recent long-distance move
involving moving away from friends and starting at a new school. She has a history of depression treated
with Prozac, menstrual irregularities, poor dietary habits, and low level of exercise. There is a maternal
family history of obesity, depression, cardiac disease, and prostate cancer.

REVIEW OF SYMPTOMS:

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GENERAL: Positive for weight gain. Negative for fever/chills, fatigue, and night sweats.

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HEAD/NECK: Negative for reports of headache, neck pain, vertigo and dizziness.

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EENT: Negative for sinus pain/pressure, ear pain/pressure, sore throat, runny nose, tongue/lip swelling
or visual changes. rs e
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CARDIAC: Negative for chest pain, pressure, tightness or palpitations

RESPIRATORY: Positive for loud snoring. Negative for shortness of breath, cough, or wheezing
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GI/GU: Negative for abdominal tenderness, n/v/d, constipation, or heartburn

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HEME/LYMPH: Negative for swollen lymph nodes in neck. Negative for bleeding/easy bruising.

SKIN: Positive for changes in skin color on the neck and axillae. Positive for increased hair growth on the
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face.
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MS: Negative for muscle pain and/or joint stiffness

MEDICAL HISTORY: Depression

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SURGICAL HISTORY: None

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FAMILY HISTORY: Obesity, depression, cardiac disease, and prostate cancer (all maternal side)

SOCIAL HISTORY: 12-year old student with elevated stress level. Hearty appetite, low level of activity.
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ALLERGIES: None

MEDICATIONS: Prozac

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 OBJECTIVE:

VITAL SIGNS: BP- 135/90, HR- 80, RR- 20, Height 5’3”, Weight 157lbs, BMI- 27.8 (need O2)

PHYSICAL EXAMINATION:

GENERAL: Alert and oriented x3. No distress noted. Non-toxic in appearance.

HEAD/NECK: Normocephalic. Full ROM in neck. No facial swelling or erythema. Positive for adipose
tissue or early development of cervicodorsal hump.

NEURO: Cranial nerves 2-12 grossly intact. No focal neurologic findings and no papilledema.

EENT: Ears: TMs pearly gray bilaterally with visible landmarks and light reflex, ear canals patent. Eyes:
PERRLA, sclera white. Nose/Sinus: No sinus pain/pressure upon palpation, nostrils are pink, moist and
patent. Throat: No hoarseness. No pharyngeal erythema. Grade 3 tonsils with no exudate. Lips are pink
and without swelling.

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CARDIAC: RRR. S1 and S2 present. No murmurs noted. No carotid bruit and JVP is WNL. No edema noted

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to bilateral lower extremities.

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RESPIRATORY: Chest is symmetrical with even and easy respirations. Clear to auscultation. No rhonchi,

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rales, or wheezing noted.

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GI/GU: Abdomen is non-protuberant and soft with normoactive bowel sounds in all quadrants. Tympanic
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percussion throughout. No tenderness noted.

HEME/LYMPH: Non-tender and normal sized anterior/posterior cervical lymph nodes. No evidence of
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bleeding/easy bruising.
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SKIN: Appropriate skin tone. Warm to touch. No edema, cyanosis and no petechia noted. Positive for
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hirsutism. Positive for increase facial acne. Positive for acanthosis nigricans to the neck and axillae.

MS: Normal muscle tone. Equal strength bilaterally. Negative for muscle pain and joint stiffness.
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DIAGNOSTICS:
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LABS: Fasting plasma glucose, hemoglobin A1C, total cholesterol, triglycerides, low-density lipoprotein
cholesterol, high-density lipoprotein cholesterol, total testosterone level, luteinizing hormone, and
follicle stimulating hormone
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RADIOLOGY: None at this time

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OTHER: Nocturnal Polysomnography

DIAGNOSIS INCLUDING DIFFERENTIALS:

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EXOGENOUS ADOLESCENT OBESITY- Child or adolescent obesity is cause by a combination of genes,

behaviors, and environmental factors. The family history suggests a genetic predisposition for weight
gain. Her dietary, exercise and psychosocial history including recent increased stress and depression all
support the diagnosis of exogenous adolescent obesity. It is unknown when the obesity was first noticed
by medical professionals due to the lack of previous documentation, but according to the patient and

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 mother, the weight gain has accelerated over the last year. This is likely provoked by the increased stress
from moving. Obesity has been confirmed due to the BMI of 27.8 which is in the 97 th percentile. Upon
examination today she is hypertensive, but multiple high readings will be needed along with the
appropriately fitting cuff will be needed to confirm hypertension as a diagnosis. Hypertension often
accompanies obesity. The patient has multiple other issues often caused by obesity such as acanthosis
nigricans, acne exacerbation, a cervicodorsal hump, and loud snoring which is a sign of sleep apnea that
has been linked to obesity.

POLYCYSTIC OVARY SYNDROME- This diagnosis is less likely. Alison has some symptoms of POS such as
obesity, acne, and history of possible hirsutism although her facial hair is minimal. Menstrual
abnormalities often frequent the diagnosis of POS and Alison has had a short history of irregularities, but
this could also be caused by her increased stress level due to the recent move.

CUSHING SYNDROME- Unlikely. This condition is rare. Alison does have some symptoms of Cushing
syndrome such as obesity, fullness of the back of neck, acne, borderline hirsutism, menstrual
irregularities, and possible hypertension. All of these symptoms are also related to obesity. Symptoms

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that Alison does not have that make this an unlikely diagnosis are facial fullness, and she is not taking
glucocorticoid containing medications.

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PLAN:

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Educate patient/family on how to monitor blood pressure and ask them to keep a daily log
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Educate patient on proper diet- keep log of food intake and bring to next appointment. limit snacking
and sodas
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Promote exercise program- keep a daily log of exercise regimen

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Continue Prozac as previously prescribed

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Follow up in the office in 7 days to review lab work and review blood pressure log

Refer to dietitian for further education and monitoring of diet

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