S: CC: Missed menses

Miss Norria is a 24-year-old female who presents complaining of missed periods.

Her last period was three months prior. No missed periods prior, though there
was some change in predictability moving from one a month to variability from
25 to 33 days. She was 11 years old when she had her first period. Describes
normal flow at five days which has decreased to three days and decrease in
amount to just one pad per day. She admits to being sexually active in using
protection with the rhythmic method. No prior histories of pregnancy. She
performed home pregnancy test which was negative. Admits to some breast
tenderness and nausea after running. Denies breast discharge, fatigue, weight
gain, abdominal pain, visual changes, or vaginal discharge.
Social History: 1500 cal vegan diet, runs 10 miles/day.
Denies alcohol, tobacco or drugs. Occupation - Pilates instructor.
Denies medical conditions, allergies, surgical or hospitalization history.
Family History: mother died at 50-breast cancer. Father: smoker/lung disease
Medications: vitamin supplement to support vegan diets
O: VS: BP 112/62, Resp 12 bpm, T 98.5 F, P 58 bpm, W: 116 lbs, Ht 5'6''
HEENT: head symmetrical, no facial hair. Peripheral fields intact. Teeth
without erosions.
Neck: symmetrical without thyroidmegaly or thyroid nodules
Lungs: clear to auscultation throughout
Heart: regular rhythm, S1 S2 without S3 or S4, murmur
Abdomen: scaphoid. Normoactive bowel sounds without bruits. Palpation
without tenderness masses or organomegaly. Non-palpable uterus.
Breast and Genitalia exams: declined by patient

A: Secondary amenorrhea – suspect

P: Pregnancy Test
hypothalamic pituitary suppression
Patient education – need to correct
low BMI
caloric deficit
Patient education – offered discussion
Calorie deficit
on pregnancy prevention alternatives
Rule out pregnancy Return to clinic in 3 to 4 weeks

Doubt pituitary adenoma Consider FSH, LH at that time