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HANDOUT ON ADOLESCENT MEDICINE

PUBERTY - NORMAL GROWTH AND DEVELOPMENT
To assess growth and development during puberty it is critical to evaluate sexual
maturity ratings as these correlate to normal growth and also physiologic changes.
Sexual maturity ratings include breast development in females, genital
development in males and pubic hair development in both males and females.
KEY HORMONES
Many of the body's hormones influence growth, such as growth hormone, thyroxine,
insulin, and corticosteroids (all of which influence growth rate), leptin (which alters
body composition), and parathyroid hormone, 1,25-dihydroxy-vitamin D, and
calcitonin (all of which affect skeletal mineralization). However, the key hormone in
growth is GH which is mediated by growth hormone-releasing hormone (GHRH) and
somatostatin (SS). Growth hormone secretion is increased by GHRH and decreased
by somatostatin. Both growth hormone levels and IGF-I (somatomedin-C) levels rise
during puberty. The increase is most marked during mid and late puberty and
correlates best with pubertal stage, bone age, and time from peak height velocity
(PHV).
The maturation of bones is influenced by thyroid hormones, adrenal androgens, and
gonadal sex steroids, mainly estrogen. An excess secretion of these hormones can
lead to advanced bone maturation, and at the time of puberty, deficiency causes
delay.
At puberty, both sex steroids and growth hormone participate in the pubertal
growth spurt. The ending of the growth spurt is secondary to epiphyseal closure,
due to the action of the sex steroids.
An increase in physical size is a universally recognized event of puberty. Average
growth velocities decrease from the first year of life until puberty from 25 cm/year
during the first year of life to 5-6 cm/year during years 5 to 10. During puberty
height velocity increases and peaks during the adolescent growth spurt. Landmarks
include:
HEIGHT
The beginning of the increase in growth velocity is about age 11 in boys and 9 in
girls but varies widely from individual to individual.
The peak height velocity occurs at a mean of 13.5 years in boys and 11.5 years in
girls.
Pubertal growth accounts for about 20% of final adult height, a total averaging 2328 cm in females and 26-28 cm in males.
The average growth spurt lasts 24-36 months.

Growth during the year of PHV in the normal female averages 9 cm/yr and varies
normally from 5.4 cm to 11.2 cm. In the normal male, the PHV averages 10.3 cm/yr
and varies normally from 5.8 cm to 13.1 cm.
Males on average are 12-13 cm taller than females primarily because of the 2-year
delay in bone closure as compared to females. This accounts for about a 10-cm
difference between the two sexes; in addition, males also have 2-3 cm more of
growth during their growth spurt.
WEIGHT
Weight velocity increases and peaks during the adolescent growth spurt.
Pubertal weight gain accounts for about 50% of an individual's ideal adult body
weight.
The onset of accelerated weight gain and the peak weight velocity (PWV) attained
are highly variable. (Normal weight for age percentile curves are available through
the Centers for Disease Control and Prevention, 6525 Belcrest Road , Hyattsville ,
MD 20782-2003 . They can also be obtained on the CDC website at:
www.cdc.gov/growthcharts/ .
Differences in Growth Spurts between Males and Females
PHV occurs about 18-24 months earlier in the female than in the male.
PHV in females averages 2 cm/yr less than in males.
PWV coincides with PHV in males, but PWV occurs 6-9 months after PHV in females.
Prediction of Mature Height
While predicting adult height is a difficult task, individuals have used both the bone
age in calculations or a measure using midparental height as most individuals have
an adult height that is within 2 inches of the midparental height. This is calculated
using:
For girls:
(father's height - 13 cm) + mother's height
2
For boys:
(father's height + 13 cm) + mother's height
2
BODY COMPOSITION

BODY MASS INDEX
Body Mass Index (BMI) is an important measure for assessment of appropriate
weight for height
BMI is determined as follows:
Metric Formula:
Weight in kilograms ÷ height in meters ÷ height in meters = BMI
English Formula:
Weight in pounds ÷ by height in inches ÷ height in inches X 703 = BMI
The BMI declines until ages 4-6 years and gradually increases through adolescence
and adulthood. Children with an earlier increase in BMI are more likely to have
increased BMIs in adulthood. BMI tables can be obtained from the National Center
for Chronic Disease Prevention and Health Promotion ( www.cdc.gov/growthcharts/)
Lean Body Mass
Lean body masses decreases in females from about 80% to 75% at maturity while in
males it increases from about 80% to about 90% at maturity due to an increase in
skeletal muscle mass. In females the percentage of body fat increases.
Skeletal Mass
The increase in skeletal muscle mass during puberty is critical and peak bone mass
is achieved by early adulthood (the lifetime "bone bank"). Epiphyseal maturation
occurs under the influence of estradiol and testosterone. The assessment of this
skeletal maturation (bone age) is an excellent index of physiological maturation and
assessment of growth potential.
Assessment of sexual maturity ratings are listed below:

Males
o Genital stage 1 (G1) : Prepubertal
 Testes: Volume less than 1.5 mL
 Phallus: Childlike
o Genital Stage 2 (G2)
 Testes: Volume 1.6-6 mL
 Scrotum: Reddened, thinner, and larger
 Phallus: No change
o Genital Stage 3 (G3)
 Testes: Volume 6-12 mL
 Scrotum: Greater enlargement
 Phallus: Increased Length

Genital Stage 4 (G4)
 Testes: Volume 12-20 mL
 Scrotum: Further enlargement and darkening
 Phallus: Increased length and circumference
o Genital stage 5 (G5)
 Testes: Volume more than 20 mL
 Scrotum and phallus: Adult
Females
o Breast stage 1 (B1)
 Breast: Prepubertal; no glandular tissue
 Areola and papilla: Areola conforms to general chest line
o Breast stage 2 (B2)
 Breast: Breast bud; small amount of glandular tissue
 Areola: Areola widens
o Breast stage 3 (B3)
 Breast: Larger and more elevation; extends beyond areolar
parameter
 Areola and papilla: Areola continues to enlarge but remains in
contour with the breast
o Breast stage 4 (B4)
 Breast: Larger and more elevation
 Areola and papilla: Areola and papilla form a mound projecting
from the breast contour
o Breast stage 5 (B5)
 Breast: Adult (size variable)
 Areola and papilla: Areola and breast in same plane, with papilla
projecting above areola
Male and female: pubic hair
o Pubic hair stage 1 (PHI)
 None
o Public hair stage 2 (PH2)
 Small amount of long, slightly pigmented, downy hair along the
base of the scrotum and phallus in the male or the labia majora
in females; vellus hair versus sexual type hair (PH3)
o Pubic hair stage 3 (PH3)
 Moderate amount of more curly, pigmented, and coarser hair,
extending more laterally
o Pubic hair stage 4 (PH4)
 Hair that resembles adult hair in coarseness and curliness but
does not extend to medial surface of thighs
o Pubic hair stage 5 (PH5)
 Adult type and quantity, extending to medial surface of thigths
o

Sexual Maturity Ratings: female pubic hair stages

click for full-size image
MALE SEXUAL DEVELOPMENT
Male sexual development generally begins with the attainment of stage G2, at an
average age of 11.6 years (range 9.5-13.5 years). The first physical sign of puberty
in 98% of males is testicular enlargement. Ejaculation often occurs during SMR3
while SMR4 is often associated with fertility but may occur during SMR3. Puberty
takes about 3 years to complete but may range from 2 to 5 years. The typical
sequence of pubertal events in males is seen below which demonstrates the usual
late occurrence of peak height velocity at an average SMR of 4. The typical
sequence is adrenarche, beginning of growth spurt, testicular development,
beginning of pubic hair, peak height velocity
Sequence of pubertal events in males:

click for full-size image
FEMALE SEXUAL DEVELOPMENT
In most females, the beginning of a breast bud is the first physical sign of puberty.
While the traditional mean age of female sexual development was in the early 11s,
over the past decade in developed countries, this age has been decreasing. For
example, in the United States , the mean age of onset of breast development is
8.87 years for African-American girls and 9.96 years for white girls. The mean ages

hormonal exposures and other environmental/societal alterations. uterus.5 years to 8 years. labia. age of PHV.78 years and 10. During puberty. the female's breasts develop and the ovaries. However. there is a correlation between adult height and the height at onset of growth spurt or height at PHV. Completion of puberty in females averages 4 years but can range from 1. Menarche occurs in 19% of adolescents during PH3 and in 5 6% during PH4. velocity at peak. and clitoris increase in size. There may be important future consequences of earlier maturation with regards to teen behavior. respectively. back to top Questions Question #1 What is the first visible sign of puberty in males? . Sequence of pubertal events in females click for full-size image There are wide variations of puberty between individuals and these are discussed in B1. Potential reasons for this decrease in age of onset. or pubertal height gain. the growth spurt starts about 1 year before breast development and this is followed by an average of 1. The typical sequence of pubertal events in females is seen below which demonstrates the usual early occurrence of peak height velocity at an average SMR of 2 and the late occurrence of menarche at an average SMR of 4.1 years until PHV and then followed in an average of 1 year by menarche. increasing obesity. might include improved nutrition. The uterus and ovaries increase in size fivefold to sevenfold. There is little or no correlation between adult height and either age of onset of growth spurt. vagina. sexual activity and pregnancy as well as future lifetime health consequences of early sexual maturation such as potential increase risk of breast cancer.51 years. while unknown.for the onset of pubic hair are 8. In the average adolescent female.

In stage II. there is sparse amount of fine non-adult hair.Answer #1 The first visible sign of puberty in males is an increase in testicular size. an increase in height velocity occurs before this although this is unlikely to be noticed in routine growth chart. click for full-size image . In stage four seen below there is normal adult hair but not quite out to medial thigh. Question #2 What is the first visible sign of puberty in females? Answer #2 Increase in breast development. However. Review of sexual maturity ratings. Question #3 The following male is about what stage of pubic hair? click for full-size image Answer #3 Stage 3 since there is a scant amount of ADULT hair.

Question #6 Most of the difference between the height of males and females is because the PHV in males is greater? True or false? Answer #6 False: About 80% of the difference between male and female height is the later age of PHV in males which allows for greater growth before epiphyseal closure. In stage two there is small breast bud and in stage 3 there is larger and more elevation of breast and areola enlarges but remains in contour with breast. which some females never attain. PHV is usually occurs earlier during puberty. it appears that there has been a reversal of the earlier onset . In females PHV is most common during SMR 2 while menarche occurs in about 2/3rds of females at about SMR 4. Question #7 In developed countries. In the photo above. there is a secondary mound and this places this teen in stage four. In stage 5.Question #4 What breast stage is indicated below? click for full-size image Answer #4 Stage 4. The difference in amount of PHV between males and females is probably responsible for about 20% of the difference. the areola flattens out Question #5 Peak height velocity is an early or late event in most females? Answer #5 In males PHV is usually a late pubertal event at about an SMR of 4 but in females.

click for full-size image The three teens above are all fourteen years of age. a normal hemoglobin level for the teen on the far left above might be in the 12. The teen complains of fatigue for about six months with no other symptoms. All three of these teens are normal for age 14. the middle about a 3 and the one on the right a 4 to 5. His examination is normal with no focal abnormal signs.0 would be normal for a teen in early development but anemic for a teen in near adult development. the blood count cannot explain the teen's fatigue while for the teen on the right. there is an increase in testosterone and thus an increase in erythropoietin levels. However. Is this teen anemic and do you have an explanation for his fatigue. You order a CBC and his hemoglobin is 12. The rising erythropoietin levels increase both skeletal muscle mass and also increase hemoglobin production. back to top Cases Case #1 A fourteen-year-old adolescent male comes to see you in the office.0 . for the teen on the left. In males. His psychosocial profile and history is normal. A hemoglobin level of 12. it is an indication of some abnormality that needs further evaluation. .0 gm/dl level.14.0 -18. with increasing SMR. Answer: This is a bit of a "trick" question as you really cannot answer the question without first knowing the sexual maturity rating of the adolescent.0 gm/DL. In conclusion. Thus.0 gm/dl while a normal level for the teen on the right might be in the 14. there is a significant correlation between SMR and hemoglobin/hematocrit levels in pubertal males. The one on the left is about a SMR of 2.of female puberty and so the average age of the start of sexual development has increased by about 6 months? True of false? Answer #7 False: In developed countries the onset of female sexual development has continued to decrease in age.

Case #2: Your next teen in the morning clinic gives you a history of feeling well but is being referred from an outside clinic for an abnormal blood test. In a female. On examination. skeletal muscle mass) to compare to a female also age 14 and SMR of 4. click for full-size image How would you expect this teens body composition (body fat. . Thus in this teen one might expect a per cent body fat of about 11% in a healthy male and over 20% in a healthy female of SMR 4. The graph below demonstrates this relationship between alkaline phosphatase levels and SMR in both males and females. This tends to peak at about the peak height velocity in males and females so occurs earlier in females. His history is completely negative as well as his psychosocial history. body fat increases. skeletal muscle mass increases and percent body fat decreases as seen in the graph below. In males. Are you concerned? Answer: This is a common occurrence in developing adolescents. With rapid bone growth. under the influence of testosterone. The teen comes in with laboratory from an outside physician that shows a normal CBC and normal chemistry panel with the exception of an alkaline phosphatase that is about 50% above normal. there are no abnormal findings and the teen is a SMR of four. alkaline phosphatase levels increase and one can find a level that might be 50100% above the normal range. Of note is that males and females have opposite affects of puberty on muscle mass and body fat. under the influence of testosterone.

The family is a critical component in the care of an adolescent and it is important for the clinician to introduce himself or herself to the family. the parents cannot be overlooked. the clinician should summarize the findings and plan with the teen and if the parents or guardians are involved. He/she should be able to communicate well with his/her patients and their parents. It is also important to spend time discussing the concerns of the parents. stepfamilies.Important for the clinician working with adolescent to like adolescents. to be included at some point in the visit. it is likely best to refer this age group to another colleague. GENERAL GUIDELINES FOR THE OFFICE VISIT There are a few important guidelines in working with teens: Liking the Adolescent . The practitioner should help to enhance family communication while assuring confidentiality when requested around personal issues. At the end of the visit. . in most cases." ( Adapted from: Committee on Care of Adolescents in Private Practice of the Society for Adolescent Medicine). and also in their parents. Involving the family . it is important for the parents. If the clinician has an aversion to adolescents and their problems. for in a real sense the family is the patient. The practitioner should be mature and open-minded. This might be at the beginning. Although the adolescent may be the primary patient. then in their problems. end or both depending on the age of the adolescent and the complexity of the problem. He/she should be genuinely interested in teenagers as persons first. Parents' input and insight are crucial. It is also important to consider that the definition of a family has changed and there may be many possible family constellations including blended families. While more of the visit may be spent with the adolescent alone. He/she should not only like teenagers but must also feel at ease with them. summarize issues that can or must be discussed with family members.click for full-size image Interviewing and communicating with adolescents Interviewing and communicating " The style and personality of the practitioner and his/her philosophy of medical care are considered to be most important in the medical care of adolescents.

peer group. family. trying to understand the teen's perspective and staying focused on what the teen is telling you. Letting the teen talk for awhile on topics or areas they feel like talking about. Discovering the hidden agenda . Treating the adolescent's comments seriously Moving from less threatening health subjects such as review of systems to more difficult topics such as sexuality and drugs.Since the adolescent may have had encounters with some adults who have been non-supportive. .While it is important to cover areas of sex. This is not the same as supporting high-risk behaviors. Family cultural and ethnic backgrounds are also critical to helping to understand the teen and their family. state. province or other locality. Using a developmentally oriented approach . It is critical for the clinician to be aware of these other issues that may be more threatening to the teen's health then their chief complaint. Ensuring confidentiality .It is important but not always easy to establish rapport with an adolescent during the first visit or several visits. a teen may come in complaining of a headache or acne. the clinician must keep in mind the developmental state of the adolescent. For example. Demonstrating concern and interest is also helpful in establishing rapport.It is very common for an adolescent to present with a complaint that does not represent the major issues that the teen is concerned about. Acting as an advocate .not only those concerns of the parents. Establishing rapport . Helpful suggestions include:       Introducing yourself to the teen and parents or guardians. The limits of confidentiality should also be discussed. It is also common that parents may present concerns that are not the major issue for the teen. Parents should also be aware of these confidentiality guidelines. this is an opportunity for the clinician to stress the teen's positive attributes. but is really concerned about being pregnant or having a sexually transmitted infection. In this regard the health care practitioner should be familiar with those laws and regulations that cover consent and confidentiality among minors in their particular country.It is critical to insure a sense of confidentiality with the teen.adoptive families and foster families. characteristics and abilities. Chatting for brief period about the teens outside activities including hobbies or school. A review of the HEADSS assessment below can help elicit this information. This can include being cautious in giving advice when asked. A 12 year old pre-pubertal male would not be asked the same questions in the same manner as would be asked a 18 year old fully mature male. Exploring the issues that concern the teen . Listening and displaying interest .Listening closely to the teen can be a key to developing rapport. and drug use.

Sex (activity.Information gathering .org/ama/pub/physician-resources/public-health/promotinghealthy-lifestyles/adolescent-health/guidelines-adolescent-preventive-services. Are you going out with anyone right now?" and something like: " As you know. It is useful to reassure confidentiality again before questions about drugs and sexuality. or both sex (es)? Has the teen had sexual intercourse? This is also to find out how many partners the teen may have and also a history of both sexually transmitted infections and contraceptive use. In some studies. Drugs What types of drugs are used by the teen's peers or family members use? What types of drugs does the teen use and what amount and frequency and is there intravenous use? This includes both alcohol and tobacco. opposite. By that I mean . This includes the topics of Home. Drugs. Again. One approach that was developed at Childrens Hospital of Los Angeles is to obtain psychosocial information using the HEADSS interview. This includes questions such as: Home Where is the teen living? Who lives with the teen? How is the teen getting along with parents and siblings? Education Is the teen in school? What classes is he or she doing well in? What goals does the teen have when he or she finishes school? If the teen is older out of school.There are several methods that might be used to elicit both health information and psychosocial information. An approach might be to ask something like: "Laurie. The area I want to discuss has to do with relationships. this is information that I will be keeping confidential. Have any of your friends tried them? and "How do you handle the situation when your friends are using drugs? Do you ever try? Sexuality Is the teen dating and what are the degree and types of sexual experience? Is the teen involved with another individual in a sexual relationship? Does the teen prefer sex with the same. There has been a growing interest in using computerized techniques to help assess health status in both teens and adults. Traditionally this is through one and one interviews. and sexual abuse). there are many teens who are sexually active. orientation. I mentioned that I might be asking some questions that were personal but very important to your health.ama-assn. What drugs are common on your campus?" and "It is not uncommon for some teens to try some of these drugs. Activities What does the teen do after school? What does the teen do to have fun and with whom? Does the teen participate in any sports activities? Community or Church activities? What are the teen's hobbies? This may be an opportunity to explore issues of seat belt safety or bicycle helmet safety. It can be useful to begin questioning with a less invasive approach such as: "I know that drugs are fairly common on school campuses. Examples for adolescents from the AMA Guidelines for Adolescent Preventive Services (GAPS) are at http://www.shtml . Education. this may even be preferred by many teens. the practitioner should ask about employment. and Suicide. Another method is a health assessment form. Activities.

lack of friends. Materials in the waiting area and clinical offices appropriate for their age group is helpful. Interview tips: Help interview tips with adolescents include:           Shaking hands with the adolescent first. Reassurance about normal findings may also be helpful. Avoiding lecturing and admonishing. substance abuse. Having a positive attitude towards the adolescent Avoiding judgmental responses .that they have had sexual intercourse. Avoiding writing during the interview. The adolescent should also have time to ask final questions. not the adolescent and highlighting the positive. early onset of sexual activity.taking a neutral stance Avoiding medical jargon Being attentive. OFFICE SETUP The space that adolescents are seen for their care can also be helpful in their overall care. Focusing on the initial history taking on the presenting complaints/problems. change in school grades. There are also many teens who have chosen not to have sexual intercourse. Also at this time resources should be discussed and a follow-up appointment made as needed.e. Closure: When the history and physical assessment are complete. is this problem the teen's concern or the parents'). Issues that should be discussed with the family should also be addressed at this time. especially during sensitive questions. the clinician should give the teen a brief summary of the proposed diagnosis and treatment. Criticizing the activity. If possible the desk in the office . genuine and empathic Identifying who has the problem (i. How have you handled this part of your relationship with Bill or with other boys you have dated? Suicide Has the teen had any prior suicide attempts? Does the teen have any current suicidal ideation? Sexual Abuse or Physical Abuse These can be critical areas to ask about particularly in adolescents with any significant problems in the areas listed above such as family dysfunction. Sometimes the true chief complaint is disclosed during the examination. The examination table should not face the door and curtain should be available for privacy. Space: Adolescents prefer not to be treated as children and the more private their space and waiting area the better.. history of suicide attempts or runaway behavior. Physical examination : The physical examination may provide another opportunity to teach the adolescent about their changing body.

. Respecting each other's privacy Keeping a sense of humor . The adolescent must realize that an insurance payment may result in parents finding out about visits and the diagnosis. If the clinician is pressed for time. not behind it. hot line numbers and reliable web site information in the waiting room or office on topics such as puberty." or "How could you do this to me?" or "Is that all? I thought it was something important. Availability of educational materials : It is helpful to place books. More time should be allotted for this visit to allow for discussing their past medical and psychosocial history." Or "in my day" or "That's a dumb thing to say" Stressing positive attributes of the adolescent. Billing : In regions where teens may be required to pay for their visit or the parents will receive a bill. PARENTS Often parents come to the health care professional with requests for help with parenting their teens. arrangements should be discussed early. Avoiding phrases such as: "The trouble with you is. or language. Appointments : Time can be a problem with the adolescent visit particularly for the first visit. especially reaching conclusions based only on appearance. Confidentiality can become a problem in certain billing situations and may require special arrangements. sexually transmitted diseases. however. a neutral diagnosis can be used in most situations. sexuality. Helpful suggestions include: Guidelines for parenting               Listening to the teenager Treating his or her comments seriously and avoid minimizing a problem. dress. Being flexible Avoiding power struggles Showing interest in the teen and their activities Spending time together both working together and having fun together Showing trust in the adolescent Avoiding comparison with other teenagers Avoiding lecturing or moralizing Avoiding overreacting.. pamphlets.should be oriented so that the health-care provider sits beside the desk. doing the history at the first visit and the physical examination on another day is a reasonable approach. and contraception.. Note taking: The practitioner should take as few notes as possible during the interview.

Teens may be eager to participate in the establishment of such rules when they find out that they might include a rule such as "no one will enter someone else's room without knocking first. A dolescents are at maximal growth velocity and change and may be more vulnerable to social risks such as drugs." Rules are mainly needed for teen or family member behaviors that are a problem and there should be a maximum of 5 10 rules. Parents must not overreact to rejection of one or both parents by the teen for a time period. fair and explicit limits around teens behavior. Invulnerability: Adolescents feelings of invulnerability also add to the risks that teens place themselves. Some examples include:    Dinner will be at about 6 PM and everyone is expected to be home and ready to eat at that time. risks of parts of sexuality. domestic violence. These include the expectations for behaviors for the family to live together as a group. Modern family issues such as less intact families and less extended families add additional challenges. most teens accept their parent's basic values. and poverty. Parents can set firm. Decisions that occur in the home about the adolescent should involve the adolescent's input and may involve the whole family. House Rules: House rules may help a family work together better. Family members are expected to speak courteously to each other. Resolving conflicts together. Experimentation by teens: Important for parents to remember that while teens may experiment with many types of behaviors. The rules should be fair and consistent with associated consequences if the rule is broken. Questions Question #1 . It is helpful to have these rules worked out with input from the whole family and for them to be written down. The violent messages added through the media add to the challenges. Before opening someone's door. parents must adapt to change in relationship with their teen. knock and wait for an answer. Other parenting issues include: As teen's peers become an increasingly important influence and the teen seeks more independence.

 Liking the Adolescent Question #2 What changes could the clinician make to a clinical setting to make it more "adolescent friendly" Answer #2 Suggestions might include:  Having appropriate materials in the waiting room and offices for teens  Setting up special times for teens to come to the clinic  Making sure the exam table does not face the door and have privacy curtains available  Allowing more time for the first visit  Discussing billing arrangements with teen and parents if billing and confidentiality issues arise Question #3 . Answer #1 Some helpful concepts during the first visit include:  Assuring confidentiality  Involving the family unless there are particular contraindications  Using good listening techniques  Being aware of the hidden agenda  Interviewing the adolescent with a developmentally oriented approach  Including a psychosocial history in the history taking  Making sure the adolescent understands the diagnosis and treatment plan.Suggest a few helpful concepts during the first visit with an adolescent and their family.

Question: . Some younger teens prefer to a parent present while others do not. She is in the waiting room with her mother.What items are critical to ask in the psychosocial history of a 16-year-old adolescent? Answer #3  Home situation  Educational/school issues  Activities and hobbies the teen is involved in  Drug use including alcohol. Cases Case #1 Part I: You are scheduled to see a sixteen-year-old adolescent female named Leslie who has recently been complaining of headaches and abdominal pain. cigarettes and other drug use  Sexuality issues including relationships. contraception.  Suicidality and mental health assessment  Sexual or physical abuse particularly in teens with higher risk profile or problems Question #4 You are about to examine a 12-year-old girl who has complaints about breast lumps? Who should be in the examination room? Answer #4 Certainly a male examiner should have a female chaperone in the exam room. types of sexual activity. sexual orientation. It might be important to ask the teen if she prefers to have her mother present. It would be less appropriate to have a parent present for an older adolescent. STIs.

They are more frequent when she has school exams or she is fighting with her parents over her friends. It would be important to introduce yourself to both the mother and the teen. An alternative approach might be to see them together to see how they interact and after obtaining some of the mom's concerns and a short family history one could excuse the mother and interview the adolescent. The mother is concerned that the teen may have some kind of tumor. You thank the mom for her concerns. She states that she seems to spend a lot of time with some guy named Tom who she does not really like. Then one could see the daughter without the mother for the physical examination. The first approach might be to see the daughter first and take the appropriate history and then have the mother come in to see what her concerns might be and how she interacts with her daughter. at the end of the examination.How would you first approach seeing this combination of adolescent and her mother? Answer: There are probably a couple of ways to approach this teen and her mother.  She discusses that the headaches are not very severe and that she has had occasional headaches when she is stressed for about 5 years. She has no associated neurologic symptoms and the headaches usually resolve with ibuprofen or over a couple of hours. Part II You see the teen and the mom together first and the mom does not let the teen really answer or give much information. Question: What information would be particularly important to obtain from this adolescent as part of the history? Answer: Medical history . that they are important and you will discuss these with her daughter. You also explain that you will be spending some time interviewing and examining the teen alone.This would information about what concerns the teen has and in particular a about her headaches and abdominal pain. You explain the importance of spending time with the adolescent alone as she is a developing adult. She mentions that the teen has been extremely difficult in recent months and does not listen to her or her husband about when to be home and how much she should be studying. it would be important to sum up the information for the teen and then bring in the mother to convey information that is not confidential. In either case. There has been no increase in severity .

She occasionally has cramps with her menses. Home situation: She lives with her mother. The abdominal pain also has been very mild and is associated with stress. Her vital signs are normal. Her neurologic examination is also normal. They are not related to eating or bowel movements and there are no other associated gastrointestinal complaints. Mental health: She states that she is usually fairly happy but she is concerned about the possibility of pregnancy and she is worried that if her parents found out they "would kill me". normal cervix and no adnexal or uterine tenderness. gonorrhea and chlamydia test. A pelvic examination shows no genital lesions. She does not talk much with her father. Part III You perform a physical examination. Her general examination is unremarkable. She discloses that Tom is her first boyfriend and that they have been having sexual intercourse for six months. You also perform a Pap smear. She mentions that the headaches and abdominal pain got worse when she started worrying about being pregnant. She has not had sex in at least two weeks. The pain is midline without radiation. They have always been somewhat irregular and occur about once every two months. father and one brother. They usually get along but recently when she has been going out with Tom she has felt her parents have been very angry with her for going out and distrustful of where she is and what she is doing. but she has been more concerned recently because she has stopped having periods for over two months. She states that she thinks she cannot get pregnant because her periods have always been irregular. Menstrual history : She had her first menses at age 12. Her last menses was over two months ago. She uses no other contraception. She has no suicidal ideation and has never been physically or sexually abused by anyone. Her abdominal examination shows no organomegaly and no tenderness. You explain the importance of a pelvic examination and what is involved. you ask about her relationship with Tom and other individuals. Drug history: She denies any drugs except for an occasional beer on the weekends and trying marijuana a few times. He uses condoms occasionally. Question: What might you wish to discuss with the teen at this point? Answer .5. Sexual history : After reassuring the teen that information about her sexuality will be confidential. She has no history of any vaginal discharge or genital lesions or history of STIs. no vaginal discharge. The teen states she is not very concerned about the pain.

This might be a good time to review with the teen issues of the possibility of pregnancy and how she might approach this if she had a positive pregnancy test. You let her know that you will be ordering a pregnancy test at this point and will review those findings first with her only. wants to start and wants to know if she can do this without discussing this with her mother. You prescribe her an oral contraceptive pill. she should be considering alternatives for additional protection against pregnancy. It is important to know the regulations for the area that you practice in. if not why not. You review contraceptive options and she chooses the birth control pill. However. not only do minors have the right to consent but that is associated with the right to confidentiality and privacy over this information. Summary of her physical findings: You reassure the teen that her history and exam do not suggest any serious problems in regards to her headaches and abdominal symptoms. and possibilities of contraception if she were not pregnant at that point. The pregnancy test is negative and the CBC is ordered. You discuss the options with the teen. This would include would she involve her parents. so one would not have the right to disclose this information to a parent. she still refuses to have the mom involved with her decision. you point out that she still could become pregnant. In fact in many areas. Question What are important issues to discuss with the teen and the mother together? Answer . As she has not had a blood test in at least ten years you order a CBC and urine pregnancy test.Possibility of pregnancy . had she thought about options if she were pregnant. In many areas. regulations allow minors to consent for prevention of pregnancy including contraception. You discuss with the teen the results of the pregnancy test and while she is reassured that she is not pregnant. you discuss the possibility of talking with the mother with you acting as a mediator with the mom. She has previously thought about oral contraceptives. It is quite possible that they are related to the stress that she is under recently. You also point out that while the condoms are a great idea to protect for STIs. Question: Can you prescribe oral contraceptives to this adolescent without her mother's knowledge or consent? Answer: The answer to this question depends on the laws and regulations in your own region or country.

org/crc/index_30160.S.     The United Nations has enacted the UN Convention on the Rights of the Child (http://www. Discussion with mom and teen about relationship with Tom: It would be important to explore Mom's concerns about the relationship. Confidentiality Issues The rights of minors and in particular adolescents can be confusing. The financing of health care services for all age groups and income levels has undergone major change In the United States . Adolescents are individuals who have more mental capacity for decision making than younger children but are not yet full adults. have constitutional rights. It would also be important at this point to assess how dysfunctional you think the relationship is between Leslie and her parents and whether you could intervene yourself with one or several follow-ups or whether at this point a referral to a counselor would be appropriate. Over the last several decades the legal framework that applies to the delivery of adolescent health care has changed in several ways." However. as well as adults.unicef.Review of the results of her history and examination. most specific legal provision that that affect adolescents' access to health care are contained in state and federal statutes or in “common law” decisions of the courts.html or see summary below) Courts have recognized that minors. parents. health care professionals and lawmakers. It becomes essential that health-care practitioners treating adolescents have a clear understanding of the legal framework within their particular country or state including checking: In most states and countries. mental health and substance abuse. Several areas are of particular concern. children under 18 have legal status that differs from that of adults. At this point you review with the mom and the teen that her history and examination suggest tension headaches and not a tumor and that both the headaches and her abdominal pains probably relate to stress from both school. the rights of adolescents took a major step with Gault in 1967. There are also significant differences between countries and individual states or provinces within countries regarding particular laws of adolescent rights to consent and confidentiality. have enacted statutes to authorize minors to give their own consent for health care in specific circumstances. These usually surround areas of reproductive health. They also may relate to some of the tension regarding the disagreements that they have over her relationship with Tom. All states in the U. There are many specific areas regarding consent and confidentiality that are particularly difficult for teens. These include: CONSENT . in which the United States Supreme Court stated that "neither the Fourteenth Amendment nor the Due Process Clause is for adults alone.

Diagnosis and treatment of reportable or contagious diseases Examination and treatment related to sexual assault Counseling and treatment for drug or alcohol problems Counseling and treatment for mental health issues. clinicians are advised to check laws in their own area. law requires the consent of a parent before medical care can be provided to a minor. A state by state analysis is available at: http://www. there are numerous exceptions to this requirement.Who is authorized to give consent for health care and whose consent is required? In general. U.S.org/graphics/gr030406_f1. Specific legal provisions in particular states that allow minors to consent for specific areas of care. Informed consent also implies that the individual has the mental capacity to given informed consent. These include:  emancipated minors  married minors  minors in the armed services  minors living apart from their parents  and in some states "mature minors" Not all states have statutes covering all of these services. However. These may include:            Consent by someone other than a biologic parent . or acquired immunodeficiency syndrome (AIDS). many states have given consent rights to minors who have special status. which most frequently fall between ages 12 and age 15 years.guttmacher.such as a foster parent. Some of these statutes contain age limits. a social worker. or probation officer Emergency situations where care may be provided without prior consent to safeguard the life and health of the minor. In addition. . Some of these include Contraceptive care Pregnancy related care Diagnosis and treatment for sexually transmitted diseases (STDs) Diagnosis and treatment of either human immunodeficiency virus (HIV). Informed consent has both ethical and legal derivations. Informed consent describes the process during which the patient learns the risks and benefits of alternative approaches to management and authorizes a course of action proposed by the clinician.html As theses vary from country to country and state to state. a juvenile court.

There are circumstances in which it is neither possible nor appropriate to maintain the confidentiality of information for legal and other reasons.Assent: Under specific legal circumstances. If the legal circumstances do not allow a minor to consent for medical treatment. clinicians are advised to check on local regulations that apply to confidentiality with minors. Safety Issues : There are also times that confidentiality/consent is important to protect teen from humiliation and discrimination that could result from disclosure of confidential information. These include:    The needs of clinical practice: Confidentiality is often needed to facilitate adolescents seeking necessary care and also in providing accurate. the minor¹s views and opinions can still be respected by obtaining assent. including medical records. candid and complete health information. Because of the potential for many conflicting regulations. even if the care is . and who has the right to receive such information? There are numerous reasons why it is important to maintain confidentiality in the delivery of health-care services to adolescents. Developmental Needs: Confidential discussions and disclosure help support the adolescents' growing sense of privacy and autonomy. This respects the decision-making skills of a minor by allowing them to participate in the decision. there is also the issue of confidentiality of services. adolescents may receive confidential care and may give informed consent for recommended care. These include situations in which the adolescent poses a severe risk of harm to himself or herself or to others. There are also specific laws in some geographic areas that require parental notification in certain circumstances. PRIVACY AND CONFIDENTIALITY Aside from consent. There are numerous country and local regulations that can affect this confidentiality. It is important to check out:       What information is confidential (since it is confidential information that is protected against disclosure)? What information is not confidential (since such information is not protected)? What exceptions are there in the confidentiality requirements? What information can be released with consent? What other mechanisms allow for discretionary disclosure? What mandates exist for reporting or disclosing confidential information? Legal Limits of Confidentiality It is important to balance the moral needs of protecting the rights of the adolescent with the legal and ethical obligations to breach this confidentiality in selected instances. and cases of suspected physical or sexual abuse for which there is a legal reporting requirement. This includes who has the right to control the release of confidential information about the health care.

pregnancy options may be confidentially discussed before informed consent is given for a pregnancy intervention. The fact that a minor has the right to consent and confidentiality of services does not necessarily guarantee payment. it is the minor rather than the parent who is responsible for payment. nor confidentiality of the information if insurance is used. Confidentiality can occur during an encounter whether or not specific informed consent for a treatment or intervention is given. In addition.html Overall the UN Convention:      Reinforces fundamental human dignity Highlights and defends the family's role in children's lives Seeks respect for children – but not at the expense of the human rights or responsibilities of others Endorses the principle of non-discrimination . One should understand that many or most hospitals and clinics will release minors medical written chart information to parents with parental consent without requiring the permission of the minor adolescent. This can present a significant barrier to care.org/crc/index_30160. when confidentiality must be breached for ethical or legal reasons. It is far more difficult to protect the confidentiality of written medical records. some consent laws specify that if a minor is authorized to consent to care. should be allowed to review their own medical records and to protect their medical records from review by others. Adolescents are uninsured and underinsured at higher rates than other groups in the population and those adolescents living below the poverty level are at the greatest risk for lacking health insurance. who are permitted to consent to their own health care. It is important to understand local regulations regarding the release of medical records of adolescents. Medical Records Confidentiality protections apply not only to verbal communications but also to written information contained in medical records. Who is financially liable for payment and is there a source of insurance coverage or public funding available that the adolescent can access.based on a teen's own consent. A source of payment is essential whether an adolescent needs care on a confidential basis or not. the adolescent should be informed. Patients. PAYMENT A last issue that arises with consent and confidentiality is occasionally that of payment of services.unicef. Finally. confidentiality and consent are different. This may break the confidentiality of information with an adolescent. Establishes clear obligations . IMPORTANT DOCUMENTS REGARDING MINORS' RIGHTS http://www. Although usually bound together in clinical encounters. For example.

Article 8: Governments must be committed to respect children's right's to preserve their nationality and identity Article 9: Children can only be separated from parents if it is in their own best interests and if that happens. Article 11: As they mature. . children have the right to freedom of thought and religion. The child's religion. They can also take part in meetings and peaceful gatherings. Parents and others have a responsibility to listen to children/youth and vice-versa. Article 15: Children have a right to join organisations and to meet with each other. culture and language must all be considered when a new home is being chosen for the child. Article 16: Children have the right to their own privacy. Article 6: Children have the right to life and must have the best possible chance to develop fully Article 7: Every child has the right to a name at birth and the right to become a citizen of a country. If a decision is being made by any organisation about a child or youth. then someone who is an interested party must be given the opportunity to take part in proceedings and have their views heard. they must be properly looked after in some other way. Article 20: If children cannot live with their family. race. then their interests must be considered when making the final decision. Article 21: Children being adopted must only be adopted under very strict rules which ensure that what is happening is in their best interests. for example. Article 17: Both parents have the main responsibilities for bringing up their children but governments are expected to recognise that some parents may need help to care properly for their children if they are both working. Article 19: Children must be kept safe from violence and they must be kept safe from harm. Article 4: Governments have made a commitment to live up to the Convention's standards Article 5: Governments must value and support parents and other adults in their roles as carers. Article 10: States shall act quickly and in a positive and humane manner in applications by families for reunification. by another family or in a children's home.

Article 24: Children have the right to be as healthy as possible. the authority must review the children's situation regularly. Different kinds of secondary school education should be available for children. Article 33: The Government shall take measures to protect children from dangerous drugs. Article 29: Schools should help children develop their skills and personality fully. Article 35: The Government shall take measures to protect children from being abducted or sold. Article 34: The Government shall protect children from sexual abuse.Article 22: States shall take appropriate measures to ensure that children who are seeking refugee status or who are refugees shall receive appropriate protection and humanitarian assistance. Article 25: If a child is cared for by a local authority. Article 28: Every child has the right to free education at primary school level. The Government must try to reduce the number of deaths in childhood and to make sure that women having babies are given good medical care. Article 27: Every child has the right to expect an adequate standard of living. Article 30: Children have the right to access their own culture. Article 31: Every child is entitled to rest and play and to have the chance to join in a wide range of activities. use their own language and practice their own religion. Article 23: Governments shall recognise that a mentally or physically disable child should enjoy a full and decent life. higher education should also be provided . The Government shall help parents to achieve this for their children. Article 26: Governments should recognise that children have the right to benefit from social security type of benefits. they must be given good health care to enable them to become well again. teach them about their own and other people's rights and prepare them for adult life. Article 36: Children shall be protected from all sorts of exploitation which can damage their welfare . Article 32: The Government shall protect children from doing work which could be dangerous or which could harm their health or interferes with their education. If they are ill. For those with ability.

html Position Paper on Confidential Health Care: Society for Adolescent Medicine Journal of Adolescent Health 1997. and in ways that would be objectionable to adolescent patients. They should have access to appropriate help including legal assistance. Article 38: The Government should respect and ensure respect for rules of international humanitarian law applicable to children during armed conflicts. or absence of confidentiality (in deference to parental wishes). Blind adherence to absolute confidentiality.cfm&ContentID=2597 Highlights of position paper:     Health providers should inform adolescent patients and their parents.Article 37: No child shall be subject to torture or inhumane treatment or punishment. No child under 15 can be enlisted into an army. is neither desirable nor required by ethics or law. Article 41: If a country's own law better meets the rights of the child than the Convention does. . The Government must publicise the Convention to parents and young people throughout their country.hri.org/AM/Template.adolescenthealth. Health providers should develop a disclosure plan for those adolescents who are deemed not to have capacity to give informed consent or for whom disclosure of information to responsible adults becomes necessary which involves adolescent wishes about the manner in which information is shared. including a full explanation of what confidential care entails and the conditions under which confidentiality might be breached. if available about the requirements of confidentiality.org/docs/ECHR50. Health providers must remain flexible when delivering confidential care to adolescents.cfm? Section=Position_Papers&Template=/CM/ContentDisplay. Article 39: The Government shall promote physical and psychological recovery and social reintegration for victims of neglect. abuse or torture.21:4008-415 http://www. Health providers must consider the manner in which written and electronic medical records might be available to parties in ways that verbal communication are not. or who are alleged to have committed a crime. should be shown respect for their human rights by those who are dealing with them. European Convention on Human Rights http://www. Confidentiality considerations regarding record keeping are necessary. then the terms of the Convention will not apply. Article 40: Children who have committed a crime.

Often the major concerns surround issues of reproductive health as in this teen. specific training is needed to increase providers' skills in effectively and appropriately incorporating confidentiality into clinical practice. lifethreatening emergency).. The exact rules on consent and confidentiality depend on your own country and state's regulations regarding consent and confidentiality among minors. the provider will abrogate this confidentiality. she is sexually active and he occasionally uses condoms. regardless. Confidentiality of Health Care: Canadian Paediatric Society . it would be very important to explore in this adolescent several issues first.Adolescent Medicine Committee Case 16-year-old female comes into the clinic with her mother for evaluation of acne and headaches. The adolescent must understand under what circumstances (e. However. Expanded efforts are needed to increase the education of health professionals regarding the laws and regulations in their jurisdiction relating to confidentiality and informed consent for adolescents. American Academy of Pediatrics Policy on Confidentiality in Adolescent Health Care (RRE9151) Key points in this policy include:     Clinicians should make every reasonable effort to encourage the adolescent to involve parents The adolescent will have an opportunity for examination and counselling apart from parents Confidentiality will be preserved between the adolescent patient and the provider as between the parent/adult and the provider. When you are taking the history.g. She also would like to get contraceptive pills if she is not pregnant. She is concerned about being pregnant. . She would like to get a pregnancy test. She asks that you do not tell her mother that she is sexually active or that she is getting a pregnancy test. Questions Can you do a pregnancy test without the mother's permission? Can you do a pelvic examination without the mother's permission? Answers These questions get to the heart of consent and confidentiality issues with teens. Her last menstrual period was two months ago. she discloses that she has a boyfriend. In addition.

You bring her mother in for a discussion of the patient's health care. often the logistics of doing a pelvic examination with the mother in the waiting room can be difficult and may entail another visit. Many countries and local states or provinces allow for confidential care of pregnancy in teens. minors have the right to contraceptive care or prevention of pregnancy without parental consent or involvement. You are practicing in an area that allows for consent and confidentiality of this health care and you reassure her about the confidentiality of this information and limitations on confidentiality. This often includes both consent and the confidentiality of that information. .  What is the nature of her relationship with her boyfriend and is it consensual  Does she have any symptoms of a sexually transmitted disease?  If she is pregnant. However. has she thought about what she might do and who she might share that information with?  Regarding the pelvic examination: This would be included in the overall consent by parents for treatment if a general consent was signed. You complete your history and physical examination. in areas where minors can consent for treatment of pregnancy. She is very concerned about what they would do if they found out about her sexual activity. After discussing this for a while. in many areas. after a discussion of the issues. You discuss oral contraceptive options with the adolescent. You also perform a urine pregnancy test and the test is negative. Usually the right of confidentiality follows the right of consent but not always. the minor could give their own consent. You also discuss management of her acne and headaches. She declines a pelvic examination at this time and would like to come back in a couple of weeks. teens are willing to share information with their parents. In addition. The teen states that she has difficult relationship with her parents. prevention of pregnancy or diagnosis of STDs. However. she is clear that she wants this information confidential. What are her reasons for not wanting to disclose and share this information with her parents? In some cases. Question Can you keep the information about the pregnancy test confidential and can you prescribe OCPs without parental involvement? Answer Again. this depends on local regulations.

there are several options:     Teen can go to a family planning or a free clinic where she might not have to pay for services. Evidence based research on preventive services guidelines is only in its infancy. prescribe OCPs.). a copy of the bill may go to the parents. If the insurance is private and the parents are holders of the policy. . it is probable that in most cases. if a test is ordered. it is important that preventive services for this age group reflect these issues.g. exercise and good nutrition) while discouraging potentially health-risk behaviors (e. they may not be responsible for payment. This is an important area of research given the limitation on health resources and the focus on evidence-based medicine. Question: Who is responsible for payment of her pelvic examination and testing? Does the insurance company have to keep her information confidential? Answer The law is not always clear on responsibility of payment. Thus.You finish with the adolescent. have her come back in several weeks to see how she is doing and to perform a pelvic examination. Teen could pay for the services herself Teen might qualify for special public funding for reproductive health services Teen might reconsider involvement of her parents. smoking. if the teen wants completely confidential care in this circumstance. environmental and social causes. In cases of care provided through public funding or HMO's this is not as likely. As many of the common morbidities and moralities of adolescence are related to preventable health conditions associated with behavioral. it is an important time to implement health promotion and preventive services. if the teen's parents have not given consent and have no information about this care. and to support healthy physical. but in many states this responsibility follows the person who gives consent. Thus.g. unsafe sexual practices. Health Screening Goal: To promote optimal physical and mental health. It is important to both reinforce positive health behaviors (e. The teen has private insurance and she is concerned that her parents might get a bill for her care. and social growth and development. As lifetime habits may form during this age group. The question of confidentiality and the insurance company is very complicated. unsafe driving etc. psychological.

152:193.Bright Futures USPSTF .American Academy of Pediatrics AMA . Arch Pediatr Adolesc Med 1998.COMPARISONS AMONG RECOMMENDATIONS FOR ADOLESCENT PREVENTIVE SERVICES (Adapted from Elster AB.American Academy of Family Physicians AAP .US Preventive Services Task Force BF USPSTF . ) Subject Immunizations ACIP recommendations Health guidance for teens Normal development Injury prevention Nutrition Physical activity Dental health Breast or testicular selfexam Skin protection Health guidance for parents Screening/counseling Obesity Contraception Tobacco use Alcohol use Substance use Hypertension Depression/suicide Eating disorders School problems Abuse Hearing Vision Tests Tuberculosis Papanicolaou test HIV infection STDs Cholesterol Urinalysis Hematocrit Periodicity of visits Target age group (yr) AAFP AAP AMA Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes No No No No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No Yes Yes Yes Yes Yes No No Tailored 13-18 Yes Yes Yes Yes Yes Yes Yes Annual 11-21 Yes Yes Yes Yes Yes No No Annual 11-21 Yes Yes Yes Yes Yes No No Annual 11-21 Yes Yes Yes Yes No No No Tailored 11-24 AAFP . Comparison of recommendations for adolescent clinical preventive services developed by national organizations.American Medical Association BF .

the guidelines of the various groups are more similar than different. and the AAP are annual visits for preventive services versus the USPSTF and AAFP which recommend visits every 1-3 years based on the specific needs of the individual.org/AM/Template. Blockades to preventive services to adolescents include:       The concept that adolescents are "generally healthy" and do not need services The reluctance of adolescents to seek care Low reimbursement rate Lack of confidentiality Transportation problems Lack of health care providers trained and interested in caring for adolescents Solutions include a broader base of health care settings including private physicians' offices. The GAPS screening forms are available at the AMA web site .Overall.health. Other useful information regarding prevention strategies in adolescents include:   Position Paper on Clinical preventive Services for Adolescents from Society for Adolescent medicine: http://www. BF.adolescenthealth.gov/healthypeople Some of these include:       Consistent use of seat belts while driving Never driving while drinking or using drugs Consistent use of condoms if sexually active Never smoking Eating a prudent diet Getting regular aerobic exercise QUESTIONNAIRES AND OTHER HEALTH SCREENING TOOLS There are several ways to obtain screening health information from teens   Interview during the routine examination.cfm? Section=Position_Papers&Template=/CM/ContentDisplay. within health maintenance organizations (HMOs). in family planning clinics and in public health clinics. in school-based health clinics.cfm&ContentID=146 4 The United States goal in Healthy People 2010 for adolescents at: www. One difference between the recommendations is the periodicity which for GAPS.These can often complement the personal interview. Use of the HEADS psychosocial intake profile is helpful as outlined in section: A4 Screening forms .

Body mass should be calculated. complementary or alternative medications.See A4 Review of systems The physical examination should include:              Height. over-the-counter medications. including prescription medications. Vision Screening Hearing Screening Sexual Maturity Rating Skin exam Teeth and Gums Neck exam for thyromegaly or adenopathy Cardiopulmonary Abdominal exam Musculoskeletal Breast exam Neurologic: Cursory unless specific neurologic problem Genitalia in males and pelvic exam as indicated in females LABORATORY TESTS Few laboratory tests are needed to screen adolescents. Weight. and nutritional supplements. These might include:  Hemoglobin: Recommended at first encounter or at the end of puberty. vitamins. The history should include               Past Medical history including Childhood infections and illnesses Prior hospitalizations and surgery Significant injuries Disabilities Medications. Further work needs to be done on the best programs and ways to implement this technology. . Computer Aided Screening and Assessment: There has been increased interest in this technology for assisting in screening. Vital Signs . Allergies Immunization history Prior developmental history and mental health history Family history including Health status and age of family members Significant physical or mental illnesses in the family Psychosocial profile .

and varicella. Part of the GAPS project has been to develop both methods of assessment and interventions.org/adolhlth/ama/pub/category/1947. recommended immunization schedule is available at www. international travel information is available at: http://www.S. IMMUNIZATIONS An immunization history should be obtained and immunizations should be updated.If a problem identified then assess level and nature of risk Problem Identification .ama-assn. solving problems in working toward a solution and shaking on a contract. GAPS: Clinical Evaluation and Management Handbook. syphilis serology and/or HIV screening should be offered.Screen for problems Assess further . Specific countries and areas should examine the recommendations of their area as these vary from country to country and even state to state. In addition. giving the teen support. Sickle cell screening in African American youth should be done if the individual has not previously tested.gov.This involves helping the teen with self-efficacy.Work with teen toward agreement on the problem and to make changes Specific Solutions. includes fully developed algorithms for each of the GAPS recommendations ( http://www.html). This age group still has significant rates for non-immunization. Sexually active adolescents should be screened for gonorrhea and chlamydia.     Routine urinalysis recommended at first encounter with an adolescent however up to 1/3 rd of healthy adolescents will have small amounts of proteinuria. MMR. Targeted or routine cholesterol screening should be done. GAPS recommends the use of the mnemonic G-A-P-S Gather information . A publication from the AMA. The current U. hepatitis A and B. If indicated by risk profile. Web Sites Available websites with preventive health guidelines include: .cdc. Tuberculosis screening with PPD should be done based on assessment of individual risk factors and recommendations of the local health department. Schedules are available from the Advisory Committee on Immunization Practices (ACIP) of the CDC. .cdc.gov/travel Potential needs in adolescents include dT booster.

org/ama/pub/physicianresources/public-health/promoting-healthy-lifestyles/adolescent-health/guidelinesadolescent-preventive-services/suicide-depression-resources.gov Recommendations on periodic health examinations based on the health risks of specific age groups.Guide to Adolescent Preventive Services . and the Medicaid Bureau of the Health Care Financing Administration.shtml Other useful links are available at the adolescent health section of AMA at http://www. the AAP also released Guidelines for Health Supervision III which more comprehensively describes the elements of health supervision visits for children and adolescents.org/ American Academy of Pediatrics The AAP has also reviewed the preventive care for children and adolescents and published revised recommendations in 1995. The recommendations are called GAPS .dhhs.brightfutures. The recommendations are evidence based or expert opinion based. These recommendations represent “a consensus by the Committee on Practice and Ambulatory Medicine in consultation with national committees and sections of the American Academy of Pediatrics.org/ama/pub/physicianresources/public-health/promoting-healthy-lifestyles/adolescent-health/guidelinesadolescent-preventive-services/screening-health-guidance-suicide-depression. Several web sites are available: For survey questionnaires: http://www.Guide to Adolescent Preventive Services.org/ama/pub/category/1947. The guidelines are both evidence-based and based on expert opinion.American Medical Association These are the comprehensive guidelines puts in place by the AMA's Division of Adolescent Health.ama-assn.shtml For actual recommendations http://www. They are available at: www.Department of Health and Human Services: http://odphp.” In 1996.html including  healthy people 2010 recommendations for adolescents  Adolescent health resources and links Bright Futures The Bright Futures (BF) guidelines for the health care supervision of infants. currently the AAP is working with Bright Futures through two cooperative MCHB grants to help facilitate usage of Bright Futures among child health . GAPS recommendations cover both the content and delivery of health care to adolescents. and adolescents were published in 1994 and represent the work of expert panels convened through a collaboration of the Maternal and Child Health Bureau of the Health Resources and Services Administration. GAPS .osophs. However. children.ama-assn.ama-assn.

aappublications.org The American Academy of Pediatrics recent guidelines are posted at http://aappolicy. The new web site starting in June 2003 will be: http://brightfutures.org/practice_guidelines/index. It is critical for health-care providers caring for adolescents to understand sexuality during the teenage period and to be familiar with ways to deal with teenagers' questions. gonads. Suddenly the 6 or 8 year old child that has been coming in for ear infections or rashes is turning into an adult.dtl These are from March 2000. The reality is that sexual development and behavior does not start during adolescence or adulthood. and hormones.htm SEXUALITY It is not always comfortable for a clinician to deal with sexual issues of adolescents. clinicians must be aware that all teenagers are sexual beings whether or not they are sexually active and also that teens engage in sexual activities other than vaginal intercourse. A FEW DEVELOPMENTAL ISSUES Preadolescent period: Biological sex is determined based on chromosomes.professionals and the public.aafp.ctfphc. feelings. However. but with childhood sexual curiosity.who.org Also available are: Canadian Task Force on Preventive Health Care http://www. An additional part of this is dealing with the consequences of sexual behaviors including sexually transmitted diseases and pregnancy. gender identity or sense of masculinity and femininity is established during this period also. The website is at: http://www.aap. The AAFP recommendations are derived from the USPSTF report by the Commission on Public Health and Scientific Affairs of the AAFP. Early Adolescence . In the process the teen is developing both physical changes but is becoming much more interested and involved in their sexual identity and relationships.int/child-adolescent-health/prevention/adolescent. and problems. In general.org World Health Organization http://www. American Academy of Family Physicians (AAFP) AAFP offers age-specific recommendations for periodic health examinations for healthy patients. During this period there is low physical and mental time spent on sexuality issues.

000 high school students from the U. December 8. only 43% of teenage females and 26% of teenage males discuss pregnancy or sexually transmitted infections with their physicians during routine exams. casual relationships of both coital and noncoital nature  Denial of consequences of sexual behaviors Late Adolescence This period is characterized by:   More expressive and less exploitative sexual behaviors More intimate sharing relationships Adolescents are filled with questions about their sexuality including?        Am I normal? Is masturbation ok? Am I ready for a sexual relationship or intercourse? How do I say no? What is safe sex? What is contraception? Am I gay? SEXUAL BEHAVIORS Given the need. do physicians address issues of adolescent sexuality? In a recent CDC news release (PACT5.S. . kissing.This period is characterized by:  Early pubertal developmental changes  Curiosity and concern over one's body and one's peers  Sexual fantasies are common as well as beginning of masturbation activity  Most sexual activity is nonphysical such as phone conversations  Middle Adolescence This period is characterized by:    Full physical maturation including menstruation in females High sexual energy with more emphasis on physical contact Sexual exploration activity including dating. 2000) it was found that in a survey of 15. UNWANTED SEXUAL EXPERIENCES Unfortunately not all adolescent sexual involvement is consensual..

health consequences of sexual intercourse. www. but through helping the adolescent in his or her decision-making process. Given this perspective. Parents can exert a strong positive influence. Respect the adolescent's privacy Be aware of community resources. Data presented by the Alan Guttmacher Institute indicates that about 74% of women who had intercourse before age 14 and 60% of those who had sex before age 15 report having had sex involuntarily (Alan Guttmacher Institute.  Over 80% of females in grades 8-11 and over 2/3 of males experienced unwanted sexual comments or actions in 1993.iwannaknow. uncensored sexuality and sexual health information.org/voy Voices of Youth. not through moralizing.edu Go Ask Alice ! . and to provide them with “responsible educational information in a relaxed. lecturing.columbia. or invasion of privacy. safe. Education: Adolescents should be informed and knowledgeable -with the aid of parents. Sponsored by the Planned Parenthood Federation of America . or community resources in areas including basic reproductive anatomy and physiology.” http://www. and fun environment.goaskalice. sex. Timing: Because sexuality begins in childhood. www. and sexual feelings. decision making skills Avoid joking about sexuality Admit personal discomfort Have available resources including books and pamphlets or web sites.com/index. 1994 Suggestions to help adolescents better deal with their sexuality include:          Listening to teen's feeling and concerns and tempering ones own reactions. Designed for youth worldwide as a venue to share ideas. basic sexual functioning. it is much less awkward to have discussions about sexuality when children grow up.unicef. it is important to treat sexuality as a natural part of life from birth onward. . Provides teens with unbiased. Source of general health and sex information maintained by Columbia University health educators.org This web page is specifically designed for teenagers to find answers to their questions about their bodies.asp TeenWire. school. Sexual intercourse in young adolescents in particular may not be voluntary. Most questions answered are submitted by high school and college-aged people. UNICEF. Web Sites Sites for Teenagers and parents www.teenwire.

org Pan American Health Organization (PAHO). MEDICAL PROBLEMS ABDOMINAL PAIN Chronic abdominal complaints are a frequent concern or complaint of adolescents and young adults. mittleschmerz. http://www.popcouncil. 2000. flatulence and belching Gynecologic conditions such as ectopic pregnancy. SIECUS Home Page . Musculoskeletal conditions like costochondritis or muscle wall strain Hepatitis and pancreatitis . http://www. www. Irritable Bowel Syndrome : Pain is usually colicky in nature and is usually more common in older adolescents and more common in females. fatigue.org Planned Parenthood Federation of America . collects.plannedparenthood. Provides information to a number of other sites.org International Planned Parenthood Federation (IPPF) . In most cases of recurrent abdominal pain in adolescents. It usually does not wake adolescents. no specific organic problem is found. One definition is three or more separate episodes of pain that occur over a 3 . and disseminates information. Differential Diagnosis includes:       Functional abdominal pain often related to stress and eating habits. promotes comprehensive education about sexuality. including adolescent health. crampy and nonspecific without radiation. . www. SIECUS. There may be associated nausea and vomiting. SIECUS develops.org The Population Council.ippf. Address the health of adolescents and youth within the context of their social and economic environment. Lactose intolerance which is associated with crampy abdominal pain.org Sexuality Information and Education Council of the U.www. . Organization conducts reproductive health research and policy work worldwide. The pain tends to be periumbilical. It distinction organic abdominal pain usually includes more localized pain and may awake the teen from sleep. The prevalence is as high as 510% or more of all adolescents. dizziness and diarrhea. . Publications cover a range of reproductive health topics. Links family planning associations in over 150 countries worldwide. and advocates the right of individuals to make responsible sexual choices.paho. diarrhea. headaches. It does not usually cause weight loss or other systemic symptoms.month period.S. ruptured ovarian cysts and pelvic inflammatory disease.siecus.

pleural effusion. acute chest syndrome with sickle cell disease and acute pulmonary embolism. The common causes of chest pain in adolescents includes:        Musculoskeletal including precordial "stitch". Screening laboratory tests include CBC. sickle cell crisis. Gastrointestinal including reflux. hyperventilation and depression Pulmonary causes including cough. cholecystitis Trauma to ribs Breast lesions or mastitis Cardiac conditions such as mitral valve prolapse. physical examination and results of screening laboratory tests. current stresses and relationship to pain. However. gastritis. peptic ulcer disease. In addition. muscle strain. The teen should be reassured that they can return to their activities and school. In contrast to adults. a physiological response to the feeling of embarrassment. Signs of systemic diseases should be looked for and a pelvic examination if indicated. the clinician needs to explain that the symptoms are real but can result from emotions and feelings. Other helpful tests might include stool alpha-antitrypsin test as screen for IBD or protein losing enteropathy as well as plain film of abdomen and H. If the diagnosis of functional abdominal pain is made. Systemic conditions : Occasionally systemic conditions in adolescents may lead to abdominal pain such as diabetic ketoacidosis. inflammatory bowel disease or obstructed bowel. The clinician can use the example of blushing. sedimentation rate. urinalysis. family history. asthma. fibromyalgia. It may be helpful to have teen keep a pain and dietary diary.    Gastrointestinal infections such as giardiasis Referred pain from lower lungs such as pneumonia or spinal cord tumor Gastrointestinal disease such as peptic ulcer disease. The history should include pain description. acute chest pain in adolescents is rarely of cardiac origin. pericarditis. careful examination of abdomen for tenderness. pleurodynia. myocarditis and rare congenital problems . pneumothorax.pylori antibody titer. rebound. ova and parasite may be needed. Diagnosis An organic disease is usually suggested by the history. basic chemistry panel and liver enzymes. Psychogenic including stress. thoracic outlet obstruction and metatstatic bone disease. the clinician will need to explain to the need the meaning of this disorder. Tietze's syndrome and much less commonly slipping rib syndrome. stool samples for occult blood. hepatosplenomegaly or masses. The examination should include height and weight and growth charts. many teens fear having a heart attach or having cancer. In addition. CHEST PAIN As many as 5% of adolescents in medical clinics complain about chest pain. More complicated or invasive tests might be needed depending on initial evaluation. costochrondritis. pneumonia.

pregnancy. anemia. allergies. IBD) and chronic fatigue syndrome. sedimentation rate and perhaps a screening chemistry panel. that decreases with rest. This may be a common complaint from parents who may be concerned that their teens seem to not be doing enough. Causes include psychosocial causes (stress. medical history. It has been linked to various viruses and may be associated with various immunological abnormalities. Symptoms that should be of particular concern to the clinician include acute chest pain precipitated by exercise. Chronic fatigue syndrome Chronic fatigue syndrome (CFS) is a clinically defined syndrome for adults that is characterized by new onset. medications. trauma. However. anxiety or depression. chest wall palpation. there are no accepted criteria for CFS in adolescents. thyroid dysfunction. inadequate sleep. breast examination and abdominal examination. Other tests would be based on the history and examination.gov/ncidod/diseases/cfs and then going to the CFS definition. infections. Many teens will not require any laboratory tests but if there is any questions. severe. mononucleosis test. The evaluation should include careful review of systems. psychosocial history including alcohol and substance use and sleep history. malignancy. recent infections. depression). FATIGUE Another common complaint among teens is fatigue. past or current mental illnesses like depression. tender lymph nodes and post exertional malaise. recent activity. The physical examination may point to an organic problem. a screening evaluation might include. headaches. bipolar affective disorder or anorexia nervosa. urinalysis. arthritis or lymphadenopathy. collagen vascular diseases. musculoskeletal or joint pains. The evaluation is similar to that discussed for general fatigue. psychotherapy and physical therapy. Important historical items include characterization of pain. cardiopulmonary examination. dizziness or syncope. Diagnosis excludes uncontrolled chronic illness. precipitating and alleviating factors. Less common problems also include herpes zoster The diagnosis is usually based on history and physical examination. . The etiology and pathophysiology is controversial and unknown. anxiety. Physical examination includes vital signs. history of fever. palpitations. weight loss. dieting. associated symptoms and recent stress. CBC with differential. The criteria for adults can be found at the CDC web site at http://www. disabling fatigue and a combination of symptoms highlighted by self-reported impairments in concentration and short-term memory. The most common cause of fatigue in teens is nonorganic representing a reaction to stress. diabetes mellitus. night sweats. low-dose antidepressants. Treatment has involved reassurance. pain that interferes with sleep or associated with dyspnea. sleep disturbances. sore throat. systemic diseases (renal. History suggestive of organic causes include fatigue that increases during the day.cdc. Most adolescents will not require any further laboratory tests and usually an electrocardiogram and chest radiograph are normal. It is less common to have teens complain of severe fatigue.

Most headaches are a result of either vascular dilation. Epidemiology By age 12 about 66% of adolescents have had headaches and this increases to 75% by age 15.HEADACHES Recurrent headaches are also a frequent problem in adolescents and young adults. pattern and chronology of the pain. This is in contrast to a isolated single very severe acute headache that may be a sign of organic disease. postseizure headache. foods. After age 12 headaches become more common in females. pseudotumor cerebri. The history should include onset. Migraine variants include hemiplegic migraine. other infections Afebrile patient: Subarachnoid hemorrhage. recurrent headaches and complete recovery between episodes Muscle tension type headaches . precipitants including stress. severe hypertension. associated symptoms. acute dental disease. photophobia or neurologic symptoms Classic Migraine: Classic migraine is associated with aura. However. Most recurrent headaches in adolescents and young adults are not associated with severe organic pathology. birth control pills and . medication and caffeine. intracerebral hemorrhage. or acute orbital disease With episodic. Common migraine is similar to classic but lacks aura and may be bilateral. post-lumbar puncture headaches. pregnancy. chronic meningitis. local extracranial disease. hydorcephalus. obstructive sleep apnea. preceding symptoms or visual symptoms. Chronic headaches but continuous or increasing in intensity after onset Intracranial mass lesions. bilateral. lacrimation and conjunctival injection on same side. illnesses. muscular contraction. or depression. Cluster headaches . Medications can be important including analgesics. they may be signs of stress. the history is the primary diagnostic tool with examination being also key. vomiting. abdominal migraine and ophthalmoplegic migraine. family history and history of motion sickness are common. steady pain and usually lack nausea. unilateral throbbing headache and also nausea and/or vomiting. substance abuse. traction of structures or local inflammation. confusional migraine. sinusitis. Photophobia. post-trauma. brain abscess. Diagnosis In diagnosing the cause of headaches. About 25% of migraine headaches begin during childhood and adolescence. anxiety. Almost 75% of teens by age 15 have experienced headaches.Associated with burning or pain behind one eye with sudden onset also rhinorrhea. depressive headaches. Differential Diagnosis            With acute severe headache Febrile patients: meningitis.Associated with bandlike.

hypersomnia (narcolepsy and excessive daytime sleepiness) and parasomnias (nightmares.tetracycline. ergot derivatives. The physical examination includes a good general examination with a careful neurological examination. Migraine headaches may respond to elimination of certain triggering items as well as stabilizing caffeine intake. Important interventions include counseling. relaxation techniques. Questions Question #1 What is the most common cause of recurrent abdominal pain in adolescents? Answer #1 Functional abdominal pain . Substance abuse history and stress history is important as well as history of migraines in the family. daily exercise. The most frequent problem in teens is insomnia involving either trouble falling asleep. Medications include simple analgesics. psychosocial history and medications and drug history. Adolescents require about 8 1/2 to 9 1/2 hours of sleep per night but actually get far less. mid adolescents about 7 1/2 hours and late adolescents about 7 hours. antiemetics. Teens with sleep problems should be asked about the type of problem. sleepwalking and nocturnal enuresis). simple analgesics or combined analgesics with both acetaminophen and nonsteroidal anti-inflammatory medications. duration. curtailing caffeine and alcohol and avoid daytime naps. A headache diary can be helpful in eliminating triggering events or foods. regularizing bedtime hours. Prophylactic treatment can include beta-blockers. bedtime habits. staying asleep or awakening too early. prior treatment. Early teens sleep about 9 hours. antidepressant medications. night terrors. family history. daytime symptoms. Therapy It is generally better to take medications sooner in the onset of the headache than later. and the triptan medications for acute severe migraine headaches. SLEEP DISORDERS Sleep problems can be a common problem in teens as either a major complaint or on the review of systems. sedative-analgesic combinations. Problems can include insomnia. calcium channel blockers and clonidine. Treatment involves identifying any organic problems and psychosocial stresses. low dose non-steroidal medications. In general. anticonvulsants (valproic acid and phenytoin). Helpful interventions in tension headaches include relaxation exercises. teens with recurrent headaches and separated by periods of complete recovery rarely need further laboratory evaluation. Neuroimaging is indicated in the acute severe headache or increasing constant headache or teens with abnormal neurological examination. frequency. Reassurance in most teens and families is a key issue. age of onset.

Question #2 Name 5 other relatively common causes of recurrent abdominal pain in adolescents? Answer #2        Irritable bowel syndrome Lactose intolerance Muscle wall inflammation or trauma Hepatitis Gynecologic infections Rupture ovarian cysts Inflammatory bowel disease Question #3 What are the most common causes of chest pain in adolescents? Answer #3     Chest wall musculoskeletal strain or trauma Stress Hyperventiliation Cough Question #4 A teen presents with 3 months of fatigue. hepatospenomegaly Question #5 What are important history and physical findings that would suggest a serious cause of headaches? Answer #5  Acute onset of severe headache . What would be important findings on history and examination that would suggest this is organic? Answer #4      History of systemic symptoms Fatigue increases throughout the day Fever Weight loss Focal examination findings such as arthritis. lymphadenopathy.

The pain does not wake her up at night. diarrhea or constipation There is not history of any of these symptoms Menstrual history and sexual history Confidentiality should be discussed before taking the sexual history. The pain appears to probably come most months in mid cycle.      Headache that is constant. Question What would be important parts of her physical examination?    Vitals signs: BP 110/76. Temperature 37. There is no radiation. Associated symptoms including nausea. Psychosocial history She lives with her parents and they get along well. She has a boyfriend and they have been having sexual intercourse for six months with occasional use of condoms. Review of systems She denies any other systemic complaints and review of systems is negative. cardiopulmonary exam to suggest chronic disease: These are all normal Abdominal examination There is no tenderness. Respirations 12. She denies any use of drugs and she denies and mental health issues. Her menses started at age 12 and has regular for several years. It is not increased or decreased with food. no organomegaly and bowel sounds are normal . The pain is crampy in nature. Her last menstrual period was about 4-5 weeks ago and her last sexual intercourse was two weeks ago. motor changes or seizures Focal neurologic signs on examination Abnormal fundoscopic examination Absence of findings suggestive of migraines such as aura. persistent is increasing in intensity Focal neurologic symptoms such as weakness. joint. What would be key history questions in this teen? Answer:      Nature of pain including severity. vomiting. photophobia Persistent vomiting Cases Case #1 A 16 year old female complains of about 5 months of occasional abdominal pain. radiation and precipitating or alleviating factors The pain occurs in lower abdomen about once or twice a month. bowel movements or exercise. She denies any vaginal discharge or genital lesions. Her weight and height are 45 th percentile Abnormalities on skin.

First. no discharge. On history you find that: Nature of pain: The pain occurs in lower abdomen and midabdomen several times a month. Bowel movements sometimes help. This would also depend on the ease of having the teen return. A menstrual calendar with a diary of her pain might help diagnosis this or establish if there are other correlations to her pain. second she is sexually active without contraception and is at risk for both STIs and pregnancy. It sometimes is worse with food intake but is not associated with exercise. It would be important to test for chlamydia and gonorrhea during the pelvic examination. although the history is not entirely clear. This adolescent has only occasionally used contraception and may be late with her menses. it would be important to discuss with her the potential issues of pregnancy and STIs and explore what options she would like to go in. consensuality of the intercourse. one possibility would be mittleschmerz. a pelvic examination should be performed. There would appear to be no history to suggest serious organic disease or systemic disease. and because she has abdominal complaints. It would also be important to discuss the possibility of pregnancy and to obtain a pregnancy test. It would be important to explore the nature of her relationship including age of partner. Pelvic examination Because the adolescent is sexually active. she is not contracepting well. no cervical motion tenderness. she has the history of abdominal pain. if it could not be performed at that time. third is the issue of a possibility of delayed menses and pregnancy. recommendations are moving into possibly waiting until three years after the onset of sexual activity to perform first pelvic exam. . The pelvic examination shows no external genital lesions. Case #2 A 15 year old male complains of about 6 months of recurrent abdominal pain. It would also be important to discuss more reliable forms of contraception and other options including hormonal contraceptive options and more consistent use of condoms. It could either be performed at that time or in the very near future. it could be rescheduled for near future. The pain is crampy in nature. The pain seems to come mainly at the time of mid-cycle. uterine or adnexal tenderness or masses. In regards to her reproductive issues. Because she has no acute symptoms and because she has no vaginal complaints and she has no abdominal tenderness. In regards to her abdominal pain. A pap smear could be done at this point although. The pain does not wake her up at night. It may last from hours to on and off for several days. There is no radiation. Question What would you do at this point in time? Answer There are several issues at the present time.

There is occasional history of constipation.Associated symptoms : There is no history of nausea. Regarding the abdominal pain. He feels she is watching over him all the time. In addition. so bringing the mom in and reviewing the evaluation of the abdominal pain with the two together may be helpful. Temperature 37. Psychosocial history : The teen lives with his mother has mom is divorced. there appears to be some significant conflict between the teen and his mother. The teen is not sexually active and has no sexual relationships. Question What would be your next steps? Answer There are several issues significant issues at this point. sed rate of 10 mm/hour and no abnormalities on chemistry panel. He states he fights with her all the time as she does not let him "live his own life". Obviously there are . joint. He has tried marijuana. Blood tests show normal CBC. Examination :    Vitals signs: BP 120/80 Respiration 16. In addition. He admits to drinking heavily on the weekends and occasionally using other drugs. His weight and height are 55 th percentile There are no abnormalities on skin. There is no rebound tenderness. He has been doing poorly in school with a below average grades that have worsen in past year. Review of systems : Occasionally has headaches and occasional trouble getting to sleep. sedimentation rate and perhaps a screening chemistry panel. The teen is also doing poorly in school and this has worsen. He occasionally get very depressed and has once or twice thought of taking a bottle of the pills his mother keeps in her cabinet. Regarding his psychosocial history: It would be important to get a complete history from the mother on her perspectives on both the abdominal pain and her thoughts on how things are going with her son. some basic screening laboratory might be in order including a CBC.    Sexual history: Confidentiality is discussed. cardiopulmonary exam to suggest a chronic disease: Abdominal examination: There is minimal tenderness in midabdomen and no organomegaly and bowel sounds are normal. he appears to be drinking heavily and has a history of depression and perhaps suicidal ideation. There are no masses. However. It would also be important to evaluate how the two react together. There is nothing on the history to suggest an organic etiology and there is much to suggest that the pain may be functional and stress related. First is the abdominal pain that the teen is concerned about. vomiting.

Recent stress There is no history of recent stress and teen is doing well at home and at school. no asthma and no history of cough. then an immediate referral would be necessary. Associated symptoms There is no history of shortness of breath. Case #3 A 15 year old comes in complaining of 3 months of occasional chest pain. It is worse with coughing or deep breathing. Question What would be the important historical questions in this teen?          Answer Characterization of pain The pain is a sharp but occasionally aching pain in anterior chest. Family history There is no family history of cardiovascular diseases. Teen does not smoke. Precipitating and alleviating factors Unrelated to food intake. If very high.significant issues with the teen and the family unit. In this case. wheezing. lightheadedness or paresthesias. It does not awaken the teen at night. While initially somewhat reluctant he is willing to see your colleague for individual and family sessions. dyspnea on exertion. These are scheduled as well as scheduling a follow-up with the teen for his abdominal pain. Question What are important things to be checking on physical examination: . Recent trauma There is no history of any recent trauma Recent infections or systemic illness There is no history of any recent infections. You discuss that with the teen the probability that the pain is related to some of the difficulties he is experiencing and that some additional help with his relationship with his mother might be helpful to sort things out. there is no current desire to hurt himself and no current or past plan or attempts. It would be important to assess with the teen alone his degree of suicidal ideation. He is also asked to keep a diary of his pain. the teen has no serious illnesses. The pain does not prevent him from doing his normal activities. The pain is unrelated to exercise or meals but his occasionally worse on movement or turning his body. Medications or drugs Teen is on no medications and has no used any illicit drugs. syncope.

Answer       General state Teen is in no acute distress and appears healthy Vital signs BP 110/80. the negative history of trauma or infections. Breast exam There is no gynecomastia and no breast tenderness Abdominal examination There is no tenderness or masses or organomegaly Question What is the most likely diagnosis? Answer Given the negative history to suggest any chronic disease. There is no swelling or masses. the negative history of association with exercise but some increase with movement and the exam showing tenderness at the costochondral junction. There is no evidence of trauma. pulse: 80. . The heart sounds are normal with no murmurs or clicks. height and weight: 40 th percentile Chest wall palpation There is slight tenderness along the left costochondral junction at about the third and fourth ribs. respirations 12. Cardiopulmonary examination The pulmonary exam is normal with normal bilateral breath sounds and no rales or rubs. the most likely diagnosis is costochondritis.