Age: 12.0
Sex: F
Vaccine: HPV9
Symptoms: Alopecia, Blood thyroid stimulating hormone normal, Erythema, Full blood count normal, Metabolic function test normal
Clinical narrative: Date: 01/07/2014 10:38 AM, Historian: self, Visit Type: Office Visit. The patient is a 12 year 2 month old female who presents with hair loss. History of Present Illness: Hair Loss. The symptoms began 1 month ago. The patient started her periods the end of October and received her second GARDASIL vaccine December 2nd. Mom is not sure if either of these factors are playing a role. Mom is concerned about noticeable bald spots that have been occurring. Past Medical/Surgical History Condition Year Procedure/Surgery Year ligament repair L thumb 2010. Medications (Active prior to today's visit) None. Allergies: Reviewed, no changes. Ingredient Reaction Medication Name Comment PENICILLINS, AMOXICILLIN. Review of Systems: System Neg/Pos Details Constitutional Negative Chills, decreased activity, fever, weight gain and weight loss. ENMT Negative Hearing loss and nasal congestion. Eyes Negative Vision loss. Respiratory Negative Cough and known TB exposure. Cardio Negative Chest pain. GI Negative Abdominal pain, constipation, decreased appetite and diarrhea. GU Negative Dysmenorrhea, dysuria and menorrhagia. Neuro Negative Headache. Psych Negative Behavioral changes, distorted body image and self conscious. Psych Positive Inappropriate interaction. Integumentary Positive Crusting, Erythema, Hair loss (The severity is described as moderate. Chronology: sudden), Swelling. Integumentary Negative Painful rash, pruritus, rash, skin cracking and urticaria. Hema/Lymph Negative Easy bleeding and easy bruising. Vital Signs Height Time ft in cm Last Measured Method % 12:59 PM 5 0.25 01/07/2014 measured 50. Weight/BSA/BMI Time lb oz kg Context % BMI kg/m2 BSA m2 12:59 PM 123.4 dressed without shoes 88 23.9. Blood Pressure Time BP mmHg Position Side Site Method Cuff Size 12:59 PM 114/67 sitting right brachial automatic adult. Temperature/Pulse/Respiration Time Temp F Temp C Temp Site Pulse/min Pattern Resp/min 12:59 PM 82 regular 16. Pain Scale Time Pain Score Method HAQ Score 12:59 PM 0/10. Numeric Pain Intensity Scale Measured By Time Measured by 12:59 PM. Physical Exam: Exam Findings Details Constitutional Normal No acute distress. Well Nourished. Well developed. Eyes Normal Conjunctiva - Right: Normal, Left: Normal. Pupil - Right: Normal, Left: Normal. Ears Normal Inspection - Right: Normal, Left: Normal. Canal - Right: Normal, Left: Normal. TM - Right: Normal, Left: Normal. Nasopharynx Normal Nares - Right: Normal, Left: Normal. Lips/teeth/gums - Normal. Palate & uvula - Normal. Oropharynx - Normal. Respiratory Normal Auscultation - Normal. Cough - Absent. Effort - Normal. Cardiovascular Normal Heart rate - Regular rate. Rhythm - Regular. Skin * Hair - Finding: alopecia. Skin Normal General inspection - Normal. Psychiatric Normal Oriented to time, place, person and situation Behavior appropriate for age. Assessment/Plan Hair loss (704.00). Iron/IBC and FERRITIN to be performed today. CBC, TSH and CMP to be performed today. We will update labs today to rule out any underlying factors but I suspect symptoms are caused by Telogen Effluvium as a response to her vaccinations, starting menstruation, and stress with her cousin starting in October.  Symptoms should resolve within the next 6 months and within the year her hair should be back to normal thickness. The patient was checked out at 1:49 PM by PAC. The following were given to the patient or verified prior to patient leaving the office: patient plan and lab orders. Provider: PAC 01/07/2014. Document generated by: PAC01/07/2014 03:09 PM. Electronically signed by PAC on 01/07/2014 05:03 PM.