Adolescent Medicine

• Core 1 (Pre-Clerkship)
  • Biomedical Science
    • Microbiology I
      • Gonorrhea, Chlamydia, Syphilis, HIV and AIDS
• Core 2 (Clerkships)
  • Pediatric Clerkship Didactics on Primary Care
• Core 3 (Post-Clerkship)
  • Electives that may further knowledge: Adolescent Medicine, Child and Adolescent Psychiatry, Endocrinology, Gender Clinic

A 15-year-old girl presents to the clinic with her mother for a well child visit, but her mother expresses concern about her daughter's recent changes in behavior. Over the past few months, the girl has been experiencing significant insomnia, struggling to fall asleep and often waking up in the middle of the night. She has lost about 10 pounds due to a decreased appetite. Additionally, she reports difficulty concentrating in school, which has led to declining grades and increased frustration. Her mother notes that she seems more irritable and withdrawn, spending less time with friends and more time alone in her room. 

Use the SSHADESS framework to guide a strength-based psychosocial history:  

• Strengths: Begin by identifying the adolescent’s strengths, such as hobbies, talents, or positive relationships.  

• School: Ask about academic performance, relationships with teachers and peers, and any challenges at school.  

• Home: Explore family dynamics, living situation, and sources of support or stress at home. 

• Activities: Discuss extracurricular activities, social engagement, and how the adolescent spends their free time.  

• Drugs/Substance Use: Screen for use of alcohol, tobacco, vaping, or other substances.  

• Emotions/Eating: Assess for signs of depression, anxiety, or other emotional concerns. Ask about eating habits and body image.  

• Sexuality: Inquire about sexual activity, orientation, and relationships. Provide a safe space for open discussion.  

• Safety: Address concerns about bullying, abuse, violence, or risky behaviors like unsafe driving or internet use.  

The physical exam for adolescents, including sports physicals, should be comprehensive and tailored to the patient’s needs. It includes general health assessment, screening for specific conditions, and evaluation of pubertal development.  

General Physical Exam  

• Vital Signs: Measure height, weight, BMI, blood pressure, and heart rate.  
• Skin: Inspect for acne, rashes, or signs of self-harm.  
• HEENT: Evaluate vision, hearing, and dental health.  
• Cardiovascular: Auscultate for murmurs or irregular rhythms. Pay special attention to signs of hypertrophic cardiomyopathy, a leading cause of sudden cardiac death in young athletes.  
• Musculoskeletal: Assess joint range of motion, strength, and flexibility. Look for asymmetry, scoliosis, or prior injuries that may affect sports participation.  
• Abdomen: Palpate for organomegaly or tenderness.  
• Genitourinary: For males, assess for hernias, testicular masses, or varicoceles. For females, inquire about menstrual history and assess for signs of menstrual disorders. Record pubertal development using the Tanner Sexual Maturity Rating (SMR) scale. This includes assessment of breast development and pubic hair in females, and genital development and pubic hair in males. Tanner staging helps identify delayed or precocious puberty, which may require further evaluation. 

Sports Physical Exam  

• Preparticipation Physical Evaluation (PPE): Focus on identifying conditions that may limit safe participation in sports.  
• Cardiac screening: Ask about family history of sudden cardiac death or arrhythmias. Perform a thorough cardiac exam, including auscultation in both supine and standing positions.  
• Musculoskeletal screening: Evaluate for prior injuries, joint instability, or conditions like Osgood-Schlatter disease.  
• Neurological screening: Assess for history of concussions or seizures.  
• Mental health screening: Screen for bullying, hazing, sexual abuse, and sleep disorders, which can significantly affect mental health in athletes. 
• Substance use screening 

Evaluation and Management  

• Mental Health Screening: Use tools like PHQ-9 Modified for Adolescents (PHQ-9A), Generalized Anxiety Disorder (GAD-7), Columbia-Suicide Severity Rating Scale (C-SSRS). Refer to mental health services and/or provide appropriate pharmacotherapy if necessary. 
• Substance Use Screening: Use validated tools like CRAFFT for substance use assessment. Provide counseling and resources.  
• Vaccinations: Ensure up-to-date vaccinations, including Tdap, HPV, and meningococcal vaccines.  
• Sexual Health: Provide STI screening and contraceptive counseling as appropriate.  
• Diet and Exercise Counseling: Provide tailored advice for healthy habits. Collaborate with a nutritionist if necessary.  
• Parent-Adolescent Communication: Encourage parents to maintain open and honest communication with their teens.  

STI Screening per the CDC: 

• Annual chlamydia and gonorrhea screening for all sexually active females under 25 years old.  
• HIV screening for all adolescents at least once between ages 13-64, with annual testing for those at higher risk.  
• Syphilis screening for adolescents at increased risk (e.g., those with multiple partners or engaging in unprotected sex).  
• Provide counseling on safe sexual practices and offer HPV vaccination if not already completed.  

Dyslipidemia Screening  

• Universal lipid screening is recommended once between ages 9-11 and again between ages 17-21.  
• Adolescents with risk factors (e.g., obesity, family history of early cardiovascular disease) should undergo earlier and more frequent screening. 

Anticipatory Guidance for Parents and Adolescents:  

Adolescence is a dynamic period of development marked by rapid physical, cognitive, emotional, and social changes. It begins with puberty and extends into the mid-20s, as individuals transition from childhood to adulthood. During this time, adolescents experience significant brain development, particularly in the limbic system, which governs emotions and reward-seeking, and the prefrontal cortex, responsible for decision-making and self-control. The limbic system matures earlier, while the prefrontal cortex develops more slowly, creating a natural imbalance that makes adolescents more prone to impulsivity and risk-taking behaviors. This heightened inclination toward risk is not only normal but also essential for learning and growth, as it encourages exploration, independence, and the development of new skills and relationships. Teenagers are also highly sensitive to peer influence and social rewards, which further amplifies their drive to take risks in social contexts. Understanding these developmental processes helps caregivers and professionals support adolescents in navigating this critical stage of life safely and effectively. Thus, it’s important to praise teenagers for healthy decisions. 

• Adolescence is a period of rapid growth and change; regular check-ups are critical for early identification of issues.  
• Normalize discussions about sensitive topics like mental health, sexual health, and substance use to build trust.  
• Adolescents often prefer private conversations—prioritize talking to them alone for part of the visit to ensure privacy and encourage autonomy.  
• Screening for safety (e.g., bullying, social media risks, driving, firearms) is essential. 
• Always consider the influence of family, school, and social environments on an adolescent’s development. 

• CHOP Outpatient Behavioral Health and Primary Care Clinical Pathway for Evaluation and Treatment of Patients at Risk for a Diagnosis of Depression 
• CHOP Outpatient Behavioral Health Care Clinical Pathway for Assessment and Care Planning for Children and Adolescents at Risk for Suicide 
• CHOP Outpatient Behavioral Health and Primary Care Clinical Pathway for the Evaluation/Treatment of Patients at Risk for Anxiety Disorder and Obsessive-Compulsive Disorder 
• CHOP Emergency Department and Primary Care Clinical Pathway for Evaluation/Treatment of Sexually Transmitted Infections in Adolescents 
• AAP Preparticipation Physical Evaluation (PPE)