CHAPTER 68 Well-Adolescent Care
A nonjudgmental approach when history taking and collection of information in a friendly, open-minded manner produce a more accurate assessment of the adolescent. Keep questions to one at a time, and find some common ground to get the adolescent talking about himself or herself. The physician should be truthful and interested in the adolescent. The HEADDSS mnemonic can be used to remember the risk-taking elements of the history (see Table 67-5). Adolescents who experiment in one area of risk taking often have contemplated or tried multiple other risk-taking behaviors. It is important to collect the information before embarking on advice. When all the risk-taking information has been gathered, the physician should choose one or two health care issues to discuss, making it clear that the information is confidential and that he or she is there to help the adolescent in a partnership way. Although the focus in adolescent care is on psychosocial issues, a general examination also needs to be performed (Table 68-1). General pediatric issues, such as immunization (see Chapter 94) and health screening, should be included (see Table 9-5).
TABLE 68-1 Examination of the Adolescent
PHYSICAL EXAMINATION—CHECKLIST
Explain to your patient what you are going to do
Explain how you are going to do it
Ask if your adolescent wants his or her parent in the room*
Be sensitive to the adolescent’s needs
Always use a sheet or blanket to provide privacy
Let the adolescent remain in his or her underwear with or without other clothes and work around clothing
Ask some questions as you go through the physical to keep the adolescent at ease. Give reassurance that elements of the physical are normal for this age
ASSESSMENT
Examination can be used to offer reassurance about normalcy†
Assess
Height/weight/body mass index and plot on percentile charts
Skin for acne
Mouth for periodontal disease
Tanner staging
Breasts and testicles
Thyroid (palpation)
Skeletal: scoliosis, Osgood-Schlatter disease, slipped capital femoral epiphysis
Mental status for depression
Signs of substance abuse, risk-taking behaviors, and trauma
* If not, you will need a chaperone.
† For example, 70% of boys can have breast enlargement (gynecomastia), and girls often have one breast larger than the other.
EARLY ADOLESCENCE (AGE 10 TO 14 YEARS)
Rapid changes in physical appearance and behavior are the major characteristics of early adolescence, leading to a great deal of self-consciousness and need for privacy. The history focuses on an overall appraisal of the early adolescent’s physical and psychosocial health.
MIDDLE ADOLESCENCE (AGE 15 TO 17 YEARS)
Autonomy and a global sense of identity are the major characteristics of middle adolescence. The history focuses on the middle adolescent’s interactions with family, school, and peers. High-risk behaviors as a result of experimentation are common.
LATE ADOLESCENCE (AGE 18 TO 21 YEARS)
Individuality and planning for the future are the major characteristics of late adolescence. Greater emphasis is placed on the late adolescent’s responsibility for his or her health.
PELVIC EXAMINATION
A full pelvic examination is rarely required in a virginal adolescent girl. A bimanual rectal-abdominal examination (all midline internal genitalia are immediately anterior to the rectal wall) is as efficient as a vaginal-abdominal examination. In some girls, especially virginal, anesthesia may be required for a full pelvic examination.
Before a pelvic examination, the patient should be informed about the importance of the assessment and what maneuvers will take place; she should be encouraged to ask questions before, during, or after the examination. In addition, a chaperone should be offered when a family caregiver is not present. The patient should be told that she has complete control over the examination and be supported to participate by using a mirror or to help guide the examiner. The patient can choose a supine or partially sitting position. The examiner should maintain eye contact during the examination. Before all maneuvers, the patient must be informed of what to expect and the sensations.
A padded examination table with the patient in a frog-leg position maximizes comfort of a pelvic examination. Stirrups can be used but are less comfortable. The examination room, lubricants, and instruments should be warm. The examination should be unhurried but efficient.
Inspection of the genitalia includes evaluation of the pubic hair, labia majora and minora, clitoris, urethra, and hymenal ring. When a speculum examination is required, it must be performed before bimanual palpation of internal genitalia because lubricants interfere with the evaluation of microscopic and microbiologic samples. The speculum allows visualization of the vaginal walls and cervical os for collection of appropriate specimens, such as cultures or Papanicolaou (Pap) smears. A Pap smear is not needed until the adolescent is sexually active, unless there is a history of sexual abuse or vulvar infection with human papillomavirus. In the rare circumstance that a vaginal examination is necessary in a virginal girl, a Huffman (0.5 inch × 4.5 inches) or Pedersen (0.9 inch × 4.5 inches) speculum should be used. A nonvirginal introitus frequently admits a small to medium-sized adult speculum.
NORMAL VARIANTS OF PUBERTY
Breast Asymmetry and Masses
It is not unusual for one breast to begin growth before, or to grow more rapidly than, the other, with resulting asymmetry. Some girls need to be reassured that after full maturation the asymmetry will be less obvious and that all women have some degree of asymmetry. The breast bud is a pea-sized mass below the nipple that is often tender. Occasionally, young women present with a breast mass; usually these are benign fibroadenomas or cysts (Table 68-2). Breast cancer is extremely rare in this age group. Ultrasound evaluation is better for evaluation of young, dense, breasts and avoids the radiation exposure of mammography.
TABLE 68-2 Etiology of Breast Masses in Adolescents
Classic or juvenile fibroadenoma (70%)
Fibrocystic disease
Breast cyst
Abscess/mastitis
Intraductal papilloma
Fat necrosis/lipoma
Cystosarcoma phyllodes (low-grade malignancy)
Adenomatous hyperplasia
Hemangioma, lymphangioma, lymphoma (rare)
Carcinoma (<1%)
Physiologic Leukorrhea
Peripubertal girls (sexual maturity rating stage III) often complain of vaginal discharge. If the discharge is clear, without symptoms of pruritus or odor, it is most likely physiologic leukorrhea, due to ovarian estrogen stimulation of the uterus and vagina. Physical examination should reveal evidence of an estrogenized vulva and hymen without erythema or excoriation. The physician should always be alert for signs of abuse. If there are symptoms, cultures should be obtained. In these circumstances, vaginal cultures can be obtained without a speculum because sexually transmitted infections are vaginal until menarche, when cervical infections are the rule. Inspection of physiologic leukorrhea shows few white blood cells, estrogen maturation of vaginal epithelial cells, and no pathogens on culture.
Irregular Menses
Menarche typically occurs approximately 2 years after thelarche, at the average age of 12.6 years. The initial menses are anovulatory and tend to be irregular in duration. This irregularity may persist for 2 to 5 years, so reassurance may be required. During this phase, estrogen feedback on the hypothalamus decreases gonadotropin secretion, which reduces estrogen production and induces an estrogen withdrawal bleed that can be prolonged and heavy. Anovulatory bleeding is usually painless. As the hypothalamic-pituitary-gonadal axis matures, the cycle becomes ovulatory, and menses are secondary to progesterone withdrawal. When ovulation is established, the average cycle length is 21 to 45 days. Some adolescents ovulate with their first cycle, as indicated by pregnancy before menarche.
Gynecomastia
Breast enlargement in boys is usually a benign, self-limited condition. Gynecomastia is noted in 50% to 60% of boys during early adolescence. It is often idiopathic, but it may be noted in various conditions (Table 68-3). Typical findings include the appearance of a 1- to 3-cm, round, freely mobile, often tender, and firm mass immediately beneath the areola during sexual maturity rating stage III. Large, hard, or fixed enlargements and masses associated with any nipple discharge warrant further investigation. Reassurance is usually the only treatment required. If the condition worsens and is associated with psychological morbidity, it may be treated with bromocriptine. Surgical treatment with reduction mammoplasty can be helpful with massive hypertrophy.