Weight loss (adolescent)

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HistoryChoose any

Menstrual historyChoose any

AssessmentChoose one

Vital signsChoose one

Percent median BMIChoose one

MeasurementChoose any

LabsChoose any

ECGChoose any

Refeeding labsChoose any

Diabetes testsChoose any

ReferralsChoose any

Additional referralsChoose any

Additional planChoose any

Supportive careChoose any

DispositionChoose one

Follow-upChoose one

Follow-up reasonChoose anyJoins the line above

Counseling paragraphChoose oneParagraph

CounselingNot in the note with these choices

Discussed the reasons for hospital admission. Caregiver expressed understanding and agreement with plan. Answered all questions.

CounselingNot in the note with these choices

Discussed the need for emergency evaluation today. Caregiver expressed understanding and agreement with plan. Answered all questions.

Note when inserted as is

Weight loss (adolescent)
• Weight history, eating patterns, and weight-control behaviors such as restriction, vomiting, laxatives, and excessive exercise reviewed
• Unintended weight loss without a clear cause; evaluation in progress
• Heart rate, blood pressure, temperature, and orthostatic vital signs stable
• Labs: CBC, CMP, ESR, CRP, fecal calprotectin, celiac panel, vitamin D, and TSH and free T4
• Nutrition referral
• Given significant weight loss with stable vital signs, workup ordered with close follow-up
• Follow up in 1 week to recheck weight and vital signs

Weight loss that is not planned needs a careful look for medical and emotional causes, and the tests and weight checks will guide the next step. Recommended supportive care with an emphasis on regular meals and snacks and avoiding dieting or extra exercise until the next visit. Return precautions given including fainting or dizziness, chest pain, a racing or very slow heartbeat, vomiting that keeps happening, feeling cold all the time, more weight loss, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

What the sources cover

Weight history and weight-control behaviors
Menstrual history
Assessment: unclear, eating disorder, GI, diabetes, thyroid, mood
Vital signs and admission criteria
Labs plus phosphorus, magnesium, UA, glucose
Cardiology referral for EKG
Psychology, psychiatry, GI, cardiology, eating disorder program

Return precautions in the template

fainting or dizzinesschest paina racing or very slow heartbeatvomiting that keeps happeningfeeling cold all the timemore weight loss

Sources

This template was built from clinical practice; no source is linked yet.