Adolescent Medicine--Routine Screening

Case

Maria, a 17 year old girl is in your office for a routine exam prior to her senior year in high school. She has been in good health and has a history of mild asthma which she treats with an albuterol inhaler. Her father has hypertension. She denies sexual activity and tells you that she has had an occasional beer. She wants to know if she needs any immunizations for college? 

 

Discussion topics

  1. How is school going?
  2. How are you getting along with friends and family members?
  3. You need to discuss contraception even though he/she is presently not sexually active. How well does he/she understand STDs? Teenagers often have misunderstandings about the effectiveness of various forms of contraception.
  4. Where are the teen's support systems and are they adequate?
  5. Driving while drinking and going into cars when the driver is intoxicated. Use seat belt at all times, even in the back seat.
  6. Drug abuse. Most 18 year olds have experimented with drugs and/or alcohol and an open discussion is welcomed by them. Encouraging them that abstinence is possible may be helpful. 
  7. Discussion of skin care and treatment of acne. Sun protection must be stressed
  8. Smoking. You must emphasize the significance of smoking, not just of tobacco but also of marijuana, and that adolescents become addicted more rapidly and they will have more difficulty quitting.
  9. Menstrual history and are there any problems?
  10. Diet and exercise. Eating disorders and body image should be discussed.
  11. Dental care and hygiene.
  12. HEADSS assessment
    • Home
      • Who lives there?
      • How things are going at home?
      • Do you feel safe at home?
      • Do you have someone to talk to at home?
    • Education
      • Grades, interests, sudden performance changes, career aspirations?
    • Activities
      • Extracurricular involvement, favorite way to pass time?
    • Drugs and alcohol
      • There are several screens, one of which is the CRAFFT Questionnaire which has been validated in adolescents as a brief screening tool that is easy to use:
        • Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been using AOD*?
        • Do you ever use AOD to RELAX, feel better about yourself, or fit in?
        • Do you every use AOD while you are by yourself, ALONE?
        • Do you ever FORGET things you did while using AOD?
        • Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?
        • Have you ever gotten into TROUBLE while you were using AOD?
          1. AOD* = Alcohol or other drugs
          2. Score >/= 2 is 92% sensitive & 82% specific for AOD treatment need
    • Sports
      • Include sports clearance questions such as history of concussion, syncope, presyncope, chest pain, palpitations, dyspnea out of proportion to exertion, family history of sudden death/drowning, injuries, use of protective equipment, sports enhancing supplements or drugs
    • Sex
      • Age at first sexual encounter (oral, anal, vaginal, penile), number of total partners, attraction and/or sexual intercourse with males, females or both.
    • Suicide
    • Safety
                    
      • Physical and sexual abuse, bullies at school or home, on the internet, gang involvement.  Also include discussion about preventative safety such as seat belts, smoke detectors, helmet use, etc

 

Physical exam

  1. Complete physical exam should be done, including a check for scoliosis
  2. Pap smears are NOT recommended for adolescents, and are held until they turn 21 years of age unless they have HIV or some other disease which can significantly weaken their immune system.
  3. Strongly consider a pelvic exam for sexually active females with abdominal pain

 

Lab evaluation

  1. If an adolescent is sexually active, screening for all sexually transmitted diseases is recommended on at least a yearly basis, more often if they had unprotected sexual intercourse
    • Chlamydia and Gonorrhea urine nucleic acid amplification tests (NAAT)
    • HIV
    • RPR
    • Urine pregnancy test for females
    • Strongly consider Hepatitis B & C serologies, especially if  un-vaccinated for Hepatitis B and if the adolescent has tattoos.
  2. Hematocrit to screen for anemia
  • At least once for males during adolescence
  • Screen all females for anemia at least every 5-10 years starting in adolescences, yearly if they have risk factors for iron deficiency (i.e., heavy menstruation, previous diagnosis of iron-deficiency, low iron intake)
  1. Tubercuolosis Screen yearly, if positive place PPD or obtain a serum Quantiferon Gold Test

 

Immunizations

  1. Three hepatitis B shots
  2. Two MMRs
  3. Adult TdaP - includes acellular pertussis booster.  Every 10 years
  4. Two Varicella vaccines if hasn't had clinical chickenpox, consider titers if unsure
  5. Meningococcus vaccine - with a booster every 5 years
  6. Human Papillomavirus Vaccine (HPV) starting at 11 years of age.  Three dose schedule at 0, 2, and 6 months.  Can be given as ealry as 9 years of age and should be given to both males & females
  7. Two Hepatitis A vaccines

 

References

  1. Adger, H et al.  Alcohol use disorders in adolescents.  Peds in Review. 2013. 34:4; 103-114
  2. Bright Futures Guidelines, American Academy of Pediatrics, Third Edition, 2010.  
  3. American College of Obstetricians & Gynecologists (ACOG) 2010 Cervical Cancer in Adolescents: Screening, Evaluation, and Management.
  4. Orr, Donald. Helping adolescents toward adulthood. Contemporary Pediatrics. May 1998
  5. Reif CJ and Elster AB. Adolescent Preventive Services. Primary Care; Clinics in Office Practice. 1998; 25(1):1-21.
  6. Metzl Jordan. Preparticipation  Examination of the Adolescent Athlete: Part 1  Pediatrics in Review June 2001
  7. Metzl Jordan Preparticipation Examination of the Adolescent Athlete: Part 2 Pediatrics in Review July 2001.
  8. Koch Jason. Performance enhancing Substances and Their Use Among Adolescent Athletes.  Ped In Review September 2002
  9. Conrad L. et al. Pharmacists' Attitude Toward And Practices with Adolescents.  Archives of Pediatrics and Adolescent Medicine. Vol 157 Aporil 2003
  10. Rosen D. Physiologic Growth and Development during Adolescence.  Pediatrics in Review June 2004
  11. Rosen D. Foster C. Delayed Puberty.  Pediatrics in Review 2001; 22
  12. 2009 Redbook
  13. http://www.ahwg.net/resources/toolkit/htm   Adoloescent Health Working Groups toolkits.  Good resource for teens

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