Treatment of Pubertal Disorders

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 body implies that he is becoming an adult too soon, which would contribute to diagnosis with the condition.
· Peripheral precocious puberty (E30.8): The patient could be diagnosed with this condition if the abnormal pubertal development is characterized by earlier functioning of his sex hormone glands.
Plan (P):
Treatment Plan: The patient’s condition does not usually require treatment. However, it will be treated using GnRH analogs, which is a group of medications that provide constant levels of serum. For this patient, the drugs will be administered through injections once every four weeks for a period of three months.
Follow-up: The patient’s response to the medications and progress will be evaluated before each injection is administered.
Patient Education and Anticipatory Guidance:
· In addition to the treatment using GnRH analogs, management of the patient’s condition will entail providing anticipatory guidance and patient education. He will receive information on pubertal changes and reassurance that these changes are normal.
· The child’s parents will receive information on how to help the child cope with these pubertal changes, how to treat him appropriately for his age, and ways of boosting his self-esteem.
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.