Week 2: Adolescent Health History and Preparticipation Sports Physical

Question 1

What is different about interviewing an adolescent? (2)

Answer 1

(1) Rapid/variable cognitive and moral development

(2) Psychosocial issues of adolescence

Question 2

Why interview adolescents about psychosocial issues?

Answer 2

The patient interview – “ a conversation with a purpose” (Bickley)

Establish a trusting and supportive relationship
Gather information
Offer information
Health promotion and counseling central to well adolescent care

Question 3

Teens most want to discuss what 3 things?

Answer 3

drugs, smoking, healthy dietary habits

Question 4

___% of teens engaging in risky behaviors have not spoken to provider about them

Answer 4

63

Question 5

3 Leading causes of death for adolescents:

Answer 5

1. accidents (MVA)
2. murder
3. suicide
4. cancer

Question 6

Why is the adolescent psycho-social screen confidential? (4)

Answer 6

1. Mature minor (common law)
2. Constitutional right to privacy
3. Ethical principle of autonomy
4. Utilitarian approach – importance of disclosure of sensitive information

Question 7

Adolescent Consent/Privacy Rights in California

Answer 7

Right to consent = right to privacy
Teens control medical records to services for which they can consent

This is NOT true in every state

Question 8

in CA, children and teens may consent to:

Answer 8

Contraception
Any services related to pregnancy, including prenatal care and abortion

There is no lower age limit in California law for these services

Question 9

In CA, at age 12, a teen can consent to:

Answer 9

• STD testing and treatment, including HIV
• Exam, treatment for sexual assault
• Discussions, counseling re drug use
• Mental health services

Remember: Parental or court consent required for any psychiatric medications for anyone under 18

Parental or court consent required for hospitalization, some exceptions for emergencies

Question 10

In CA, parental or court consent is required for any psychiatric medications for anyone under

Answer 10

18

Question 11

Emancipated Minor

Answer 11

• Legally married
• Armed services
• Legal income and legal emancipation

Question 12

Mature Minor

Answer 12

• Living apart with or w/o permission

- Managing own affairs in any way, income from any source

Question 13

Limits to Confidentiality (3 major)

Answer 13

1. Teen states intention to harm self (must inform parents/guardians)
2. Teen states intention to harm someone else (must inform victim/call police)
3. Teen discloses physical/sexual abuse/neglect (mandatory CPS report)

Question 14

Late developers may have temporary popularity/esteem issues, but generally there is a ___ effect

Answer 14

protective

Question 15

Early developers have ___  interest in risk-taking behaviors with ___ impulse control

Answer 15

increased risk taking

decreased impulse control

Question 16

SSHADESS

Answer 16

Strengths
School
Home
Activities
Drugs/substance use
Emotions/Depression
Sexuality
Safety

Question 17

HEADSSS

Answer 17

Home
Education/employment
Activities
Drugs/diet
Sexual Activity/Abuse
Suicidal ideation/depression
Safety

Question 18

Points to remember about interviewing the early adolescent (10-14)

Answer 18

• May never have been interviewed without a parent before
• May not know crucial elements of own medical history
• May never have been asked about confidential issues, such as drug use or sexuality
• May need to ease into questions
• VERY present-oriented
• Limited independence, limited skills at self-care

Question 19

Points to remember about interviewing the middle adolescent (14-16)

Answer 19

• Still relatively concrete, may not have been asked independent/confidential questions before
• May have more experience with confidential questions
  Increasing ability to remember details of own history, make and carry out plans
• May have some independent skills (taking bus, filling prescription, making own purchases)

Question 20

Points to remember about interviewing the late adolescent (16-23)

Answer 20

• Cognitively similar to adults in ability to understand, answer questions, make plans
• Brain development not yet complete, differences in reward centers, impact of emotions on frontal lobe
• Less experience, much less familiarity with medical jargon, may not understand euphemisms
• More familiarity with adolescent risks, even if not engaging in them: can ask more directly

Question 21

How are teens different than adults in terms of drugs/alcohol/tobacco? (2 key points)

Answer 21

• Binge use more common than daily use in teens

- Remorse about use less common than in adults, even with significant overuse

Question 22

CRAFFT questions pertaining to drugs/alcohol for adolescents

Answer 22

Ridden in a CAR with someone high?

Drink/drugs to RELAX or fit in?

Drink/drugs while ALONE?

FORGET things you did on alcohol/drugs?

FAMILY/FRIENDS tell you to cut down?

TROUBLE from drinking/drugs?

Question 23

Structured depression screen now recommended yearly for teens ≥

Answer 23

12

Question 24

If a teen is < 14, how old of a sexual partner do you need to report?

Answer 24

14 or older

Question 25

If a teen is < 16, how old of a sexual partner do you need to report?

Answer 25

21 or older

Question 26

Adolescent Psychosocial Screen like GAPS (AMA)/AAP/SAHM should be done when?

Answer 26

yearly ``` Well exams When care has been interrupted When teen has a physical complaint with possible psychosocial overlay (Headache GI complaints Fatigue) ```

Question 27

Sports likely for weight loss/issues

Answer 27

Boxing, wrestling Dance, gymnastics Football (increase)

Question 28

Female Adolescent Triad

Answer 28

Disordered eating Amenorrhea Osteopenia also an issue for distance endurance sports

Question 29

Sudden Cardiac Death

Answer 29

Sudden, nontraumatic, nonviolent death occurring within 6 hours of previously witnessed state of normal health most previously undiagnosed

Question 30

Most common causes of Sudden Cardiac Death

Answer 30

- Hypertrophic Cardiomyopathy (HCM) (26%) - Anomalous origin of coronary artery (14%) - other structural causes (e.g. Marfan Syndrome) - Arrhythmias (Prolonged QT, heart block)

Question 31

Hypertrophic Cardiomyopathy

Answer 31

Familial disease - unexplained L ventricular hypertrophy Usually asymptomatic in adolescence Characteristic murmur may not be present early in course Screening ECG 80-90% accurate in detection Echocardiogram to aid in diagnosis and for follow-up in those with family histories

Question 32

Severe Marfan Syndrome syndrome characterized by

Answer 32

- Long thin extremities, often associated with hyper mobility - Reduced vision 2º dislocations of lenses - Aortic aneurysms – dissection leads to SCD Incidence 1:10,000 Inherited as autosomal dominant trait, but up to 30% from spontaneous mutations

Question 33

Concussion definition (5 key points)

Answer 33

1. Caused by direct head injury OR blow elsewhere w/ impulsive force to head 2. Rapid onset short-lived neuro impairment w/ spontaneous resolution 3. Functional injury 4. Graded set of clinical symptoms – with or without LOC 5. No abnormality on imaging

Question 34

Teens are ___ coordinated during periods of rapid growth

Answer 34

less

Question 35

Ligaments are ___ than bones in early puberty, so teens are more prone to fractures vs. sprains

Answer 35

stronger

Question 36

Menses are normally ____ during first 2 years after menarche

Answer 36

irregular

Question 37

Is powerlifting ok while growth plates open (could be ages 18-20 in boys)?

Answer 37

NO! | do more repetitions of small weights

Question 38

Growth spurt for girls normally happens at what Tanner Stage?

Answer 38

3-4

Question 39

Growth spurt for boys normally happens at what Tanner Stage?

Answer 39

4-5

Question 40

Skeletal maturity (T5) for girls happens when?

Answer 40

2 years post-menarche they are 85% of adult height at menarche

Question 41

Skeletal maturity (T5) for boys happens when?

Answer 41

Age 18-20

Question 42

Menarche age range for girls

Answer 42

average: 12 range: 9-16 Tanner Stage: 3-4

Question 43

Spermarche age range for boys

Answer 43

average: 13 range: 11-15 Tanner Stage: 2-3

Question 44

BMI calculation

Answer 44

Weight in Kg ÷ (Height in meters)² Weight in Pounds ÷(Height in inches)² X 703 plot for age and gender

Question 45

Signs of Marfan Syndrome that might appear during objective part of sports exam

Answer 45

``` Armspan>height Upper/lower segment ratio Hyperflexible joints Pectus deformity Kyphoscoliosis ```

Question 46

Visual acuity concerns (2)

Answer 46

one eye only or best corrected vision >20/40

Question 47

Still's murmur

Answer 47

LLSB, apex Harsh, vibratory increased when supine decreased w/ Valsalva

Question 48

Murmur of HCM

Answer 48

LLSB, apex May be soft decreased when supine increased w/ Valsalva

Question 49

"athletic heart" - Effects of dynamic training

Answer 49

- increase in vagal tone, decrease in resting heart rate (<60) - increase in L ventricular size - increase in maximal oxygen consumption

Question 50

Detailed neurological exam NOT required if

Answer 50

Negative ROS Mental status, general appearance WNL Musculoskeletal exam WNL

Question 51

Order of sports physical exam (suggested) - 8

Answer 51

1. HEENT (start sitting or standing) 2. Nodes, thyroid 3. Respiratory/lungs 4. Cardiac: standing/sitting 5. Cardiac: Lying (can check breast Tanner Stage) 6. Abdomen, femoral pulses, Tanner Stage girls 7. 14-point ortho (standing) 8. Male GU

Question 52

Refer to cardiology for which murmurs? (5)

Answer 52

1. All diastolic murmurs 2. All holosystolic murmurs 3. Murmurs greater than or equal to 3/6 in intensity 4. Continuous murmurs (not venous hum) 5. Murmurs which  when standing or w Valsalva

Question 53

Put down minimum information necessary/be careful what you write for school forms (not EMR) when doing sports physical -- why?

Answer 53

Schools operate under FERPA NOT HIPAA: - Parents have access to all records - School may share health care information more freely than with HIPAA - Informal verbal dissemination of info among school staff allowed