Episode Transcript
Hi and Welcome to Clerkship Ready - Pediatrics - A podcast aimed at helping you excel during your clinical clerkship in Pediatrics.
I am Serwa Ertl an Adolescent medicine physician and assistant professor of Pediatrics at the University of Virginia.
During your pediatric clerkship, you will likely spend time in a clinic or practice that sees adolescents for annual well visits. The AAP recommends that well visits for adolescents start at 11 years old. The goal of the adolescent well visit is to empower the adolescent in starting to take ownership of their health with the support of their provider and caregiver.
Because so much of the well visit is based on adolescent growth and development, it is important to review both the psychosocial development of early, middle, and late adolescence and the sexual maturity rating (SMR) (previously referred to as Tanner Staging) of adolescence before the visit.
Before seeing the patient, you should review their chart to look at past medical history, medications, prior concerns from previous visits, and their last well visit if available. Vaccines should be reviewed to determine if any are needed during the visit. Review labs to ensure there are no abnormal labs that need to be addressed and to determine if any screening labs are needed based on the age of the patient or risk factors.
It is important to review the patient’s vital signs especially blood pressure to ensure the blood pressure is not elevated. Review the patient’s height, weight, BMI, and their growth chart. When reviewing the growth chart, both percentile and trend should be taken into account. If the growth chart trend is abnormal this is concerning and indicates that there is a medical problem.
For example, if a patient has weight loss, this may be concerning for decreased caloric intake, GI concern such as celiac disease/IBD, or an endocrine concerns such hyperthyroidism.
Another example is an abnormal height trend, this may be concerning for constitutional growth delay, familial short stature, or even a genetic cause such as Turner syndrome
Growth should be considered within the context of puberty and SMR staging.
Some practices may give patients a screening questionnaire to assess for mood. One example is the PHQ-9A or the patient health questionnaire modified for adolescents which screens for depression. If your clinic uses a screening questionnaire, it is helpful to review this before entering the patient room in order to ask additional questions if needed.
Entering the patient room:
When you enter the patient room, first introduce yourself to the patient and ask how they would like to be addressed during the visit. Ask who is accompanying them for the visit. It can be helpful to review the structure of the visit with the adolescent and caregiver to assist with providing an open, comfortable environment. This provides an opportunity to discuss that a portion of the interview will include having the adolescent interviewed alone and the importance of confidentiality. For example I may state, “During your well visit, I will first be asking about concerns you have, your medical history, and social history. Because our goal is to support you in starting to take ownership of your health as you continue to have increased independence, during part of our visit I will ask your parent to step out of the room so I can ask you additional questions. Anything that you tell me is confidential meaning private. However, if I have concerns regarding your safety (which can include if someone is hurting you or you are hurting someone) than I will have to break that confidentiality but I will let you know before doing so so that we can discuss a plan of how to share that information” I often use the general term “safety” in case there is a situation such as substance use disorder where the adolescent is at risk of serious harm to themselves and requires caregiver notification and involvement. In addition, it is important to make the adolescent aware that the physical exam will include a genital exam. I may say, “Your physical exam will include a genital exam (an outside exam of the penis/vagina) (and breast exam) in order to examine your development during puberty. A chaperone will be present during those portions of the exam.”
After reviewing the structure of the visit and confidentiality, then you can start the visit. Try to direct your questions towards the adolescent with use of the parent as support if the adolescent is unsure or if the parent brings up a concern that the adolescent did not.
You may start with “Are the any concerns that you would like to talk about during our visit?” If there are concerns that are separate from the topics you discuss below for the annual visit, take a focused history (onset, duration, frequency, things attempted, etc.)
Next, address any concerns from recent visits that require follow-up or updates which can may include for example recent hospitalizations, ER visits, or specialist visits.
At this time you may consider introducing components of the psychosocial exam (SSHADESS vs. HEADSS) while the caregiver is in the room with the adolescent.
The most common adolescent psychosocial screening is the HEADSS exam. The HEADSSS exam stands for home, education/employment, activities, drugs, sexuality, suicide/depression/self-image, and safety. The SSHADESS screening is a modified version of HEADSS with the goal of interviewing adolescents from a strength based format rather than just an emphasis on risk factors. The components of the SSHADESS exam are strength, school, home, activities, drugs/substance use, emotions/eating/depression, sexuality, and safety.
Therefore, if you do decide to introduce components of the HEADSSS or SSHADESS exam while the parent is in the room, the focus should be on strengths, school, and activities. The remaining parts should be performed when parents have left the room.
Strength: If you are using SSHADESS and asking about strengths in front of the parent, one way to do this is asking the parent what they are most proud of for the adolescent or what are some things the adolescent does best?
School: Next ask about school, school performance, topics they enjoy, and what they would like to do in the future.
Activities: What do you enjoy doing for fun? Are you participating in physical activity and if so how frequently?
Next, hold on asking the remaining psychosocial questions and focus on nutrition.
Diet: Nutrition is a crucial component of puberty. During puberty, adolescents have increased nutritional needs to account for their growth and development. Without an adequate amount of nutrition, puberty can be impacted. For example, severe malnutrition may result in delayed puberty. Adolescence are at risk of disordered eating and adolescence is a common time for the onset of an eating disorder. Therefore, it is important to take a detailed nutrition history and later ask if they have any concerns about their body image. You will want to know how many meals and snacks they have on a typical day. If they are skipping meals and snacks, how often does this occur during a regular week and what often causes them to skip a meal or snack. If there is concern about inadequate nutrition, take a detailed 24 hour food recall requesting that they recall what and how much they have eaten within the last 24 hours. The goal for a majority of adolescents is to have 3 meals and 2 snacks during the day. Ask about dairy intake since the body requires its highest calcium requirement (1300 mg or 4 servings/day) during adolescence in order to have adequate bone health. Ask about sources of iron especially since adolescent females are at risk of iron deficiency anemia due to menstruation. Ask about fluid intake such as water (recommendation for estimated 64 oz/day), sugary beverages, and caffeine.
Sleep: Ask how much sleep they get on a typical night. Teenagers should get 8-9 hours of sleep a night. Any difficulty falling or staying asleep? If there are sleep concerns ask additional questions about caffeine intake, what their bedtime routine is, frequency of naps during the day, weekend sleep schedule, consistent snoring, and screen time before bed.
Screen time: Ask about duration of screen time during the day and types of screen time. This can also be a good time to discuss online safety with the adolescent and caregiver.
Dental: Frequency of brushing (recommendation is for twice a day) and if they have seen a dentist within the last 6 months.
Menstrual history: Ask about menarche. If menarche has not yet occurred ask when breast development started (menarche often occurs two years after thelarche) or when immediate female family members had menarche if known. This can provide an approximate age of when the adolescent may experience menarche. If menarche has not yet occurred by 15 or 16 years old, this is concerning for primary amenorrhea requiring further evaluation. If they have had menses, ask how frequently periods occur, for how long, and how many pads/tampons are required on average each day due to soaking through or how frequently they need to change pads or tampons because of complete soaking through. Ask about menstrual cramps. If menstrual cramps are occurring ask about when they occur during the period, if they impact daily function resulting in school or work absence, and medications previously attempted for cramps.
Review medications and allergies.
Review the growth chart with the adolescent and parent.
Review vaccines.
Confidential Interview:
Now ask the parent to step out of for the remaining part of the interview. I may say “Now I am going to ask your parent to briefly leave in order to ask you some additional questions. I will also touch base with your parent separately to make sure I am addressing any additional questions or concerns they have as well.”
I will then accompany the parent as they leave the room to ask if they have any additional concerns that we did not address earlier. If there are additional concerns, again take a focused history if needed.
After you return to the adolescent’s room, remind the adolescent about confidentiality and consider normalizing the remaining sensitive questions before proceeding with the reminder of the psychosocial questions. For example, you can say “I am going to ask you questions that I ask all of my teenage patients to ensure I am addressing all of their health needs. As we discussed earlier, your answers to these questions are confidential unless I am concerned about your safety.”
Ask them if they have any questions or concerns that you did not discuss earlier.
Home: Who do you live with? Have there been any changes in your family recently? If you had concerns, would you feel comfortable talking to anyone in your family?
Drugs and substance use: Do any of your friends smoke or vape nicotine, marijuana, alcohol, prescription pills, or any other substances? Have you ever tried any of those substances? If so, what are some of the reasons for doing and what are the things you have experienced while using those substances?
Emotions, eating, and depression: Have you would you describe your current mood? Any recent stressors? Any concerns for your weight or body image? Have you been trying to lose or gain weight? Have you been feeling sad or depressed? Have you thought of hurting yourself or someone else? Have you ever tried to hurt yourself?
Sexuality: Do you consider yourself a boy, girl, or another gender? What pronouns do you use? Are you attracted to anyone? Tell me about that person. (Using gender-neutral language). How do you and your partner deal with disagreements? Are you attracted to guys, girls, both, or neither? Have you ever had sex and what do you consider to be sex (important to clarify what type of sex)? What kind of steps do you take to protect yourself during sex? How often will you forget to use condoms? If condoms are not being used, ask how do you and your partner decide if you are going to use a condom or not? Have you ever been worried that you could be pregnant? Have you ever been worried about or had a sexually transmitted infection?
Safety: Do you feel safe at school. Have you been bullied? Do you carry weapons or are there weapons at home? Do you wear a seatbelt in the car? Has anyone ever touched you physically or sexually when you didn’t want them to? (Abuse is asked in the context of safety, not sexuality.) Has your partner ever made you do something that makes you feel uncomfortable? How do you and your partner deal with disagreements in your relationship? Do you ever get into fights with your boyfriend, girlfriend, or partner? Physical fights? Have you ever seen people in your family or home hurt each other physically or verbally?
Next you will complete the physical exam.
-A few hints:
-I will often do the exam from head to toe
-If the adolescent or parent brings up a concern during the history, ensure you are paying extra attention to that area during the exam
-If acne is noticed, ask the adolescent how they treat their acne. Often acne can be embarrassing or distressing for the teenager and so they may not bring it up as a concern.
-The breast and genital exam should not be performed without a chaperone present. Often the chaperone will be your attending so that the breast and genital exams do not need to be repeated multiple times.
When you leave the room, you can prepare for your oral presentation
In your oral presentation, you will start with the adolescent’s age, sex, any brief pertinent medical history if available, and what they are here for. You will then go through your list of elements that you discussed. When you get to the physical exam, you will start with a general statement on appearance. Present the vital signs and growth parameters. Then present the exam, head to toe. End with an assessment and your plan.
Here’s an example:
Alex is a 15 year old female with a history of depression who presents for her annual well visit. She and her mother report no concerns. For depression, Alex sees her therapist weekly and is on Prozac 20 mg daily. She feels as though this adequately controls her target symptoms of irritability and decreased motivation. Her PHQ-9A was 2 and she denies recent SI and has a safety plan if she were to experience SI.
She eats 3 meals and 2 snacks a day with a variety of food groups. She drinks 2 glasses of skim milk daily and 64 ounces of water. She denies soda, juice, and additional sources of caffeine intake. Denies any concerns about weight or body image. She sleeps from 10pm-6am and denies difficulty falling or staying asleep. She estimates 5-6 hours of screen time (computer and phone) a day with a majority spent on homework assignments and 2-3 hours on social media. She and her mother have discussed limiting access to her social media to only her friends and not posting specific details about her personal life. She sees a dentist every 6 months.
She had menarche at age 13 with LMP 2 weeks ago. Menses occurs monthly for 3-4 days requiring 2-3 pads/day. She has cramps the first two days which are managed with ibuprofen and do not impact her ability to attend school or participate in activities.
She is in 10th grade at CHS and is an A student and would like to be a photographer in the future. She is most proud of recently winning 1st place in a photography contest. She likes to run 2-3 times/week with her older sister in their neighborhood. She lives with her parents and older sister and feels comfortable sharing concerns with them. Denies bullying at school. Denies substance use and none of her friends use substances. She is interested in males and has a 16 yo boyfriend she met at school. She has never had sex but feels comfortable talking about use of condoms and contraception with her partner. She feels safe at home, school, and in her relationship. Denies the presence weapons at home. She is excited to get her learner’s permit and wears a seatbelt consistently in the car.
On physical exam, Alex is a well-appearing 15 yo female. Her vital signs are normal for age, and her height, weight and BMI have all been trending at the 50th%ile. Her HEENT exam is normal. She has no adenopathy. Her lung exam is normal. She has no murmurs on her heart exam. Her abdomen is soft and nondistended. I deferred the genital exam until we can do it together. No acne appreciated. Her strength and reflexes are intact. No evidence of scoliosis on exam.
My assessment is that Alex is a healthy 15 year old female with history of anxiety with appropriate growth and development. Her depression appears well controlled with use of Prozac and therapy and minimally elevated PHQ-9. We discussed increasing her calcium intake with additional sources of dairy. We discussed online safety. In addition we discussed safe sex with consistent condom use and consideration of contraception if she and her partner were to decide to have sex. She needs her last HPV vaccine which Mom and Alex agreed to receive today. We will see her back in one year or sooner if needed.
Congratulations! You completed your first adolescent well visit! I hope you have the opportunity to see a number of adolescents during your outpatient rotation and the progression of the adolescent visit during each stage of development for early, middle, and late adolescence.
Outro:
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