Past Pediatrics I: Adolescents Exam (STUDENT) 2026 PDF

Pediatrics I: Adolescents Simple Minds - Don't You (Forget About Me) - Bing video ANGIE DEUBEL, MSPAS, PA-C UNIVERSITY OF NEW MEXICO PA PROGRAM Adolescence: Gateway to Adulthood! ...

Pediatrics I: Adolescents Simple Minds - Don't You (Forget About Me) - Bing video ANGIE DEUBEL, MSPAS, PA-C UNIVERSITY OF NEW MEXICO PA PROGRAM Adolescence: Gateway to Adulthood!  Complete puberty and physical growth  Develop socially, emotionally and cognitively  Establish an independent identity and separate from the family  Prepare for career or vocation What is puberty? Sexual maturation and achievement of fertility. Boys Girls Starts ~10-12 yrs Starts ~8-11 yrs Ends ~16-18 yrs Ends ~14-16 yrs Testicle old enlargement 1st Breast buds usu Pubic hair 1st Axillary hair Pubic hair +- 1st Muscle enlargement Axillary hair & voice deepening Menarche (Avg age Body and facial hair 12yrs) Hormones…  Pituitary and gonadal hormones low prior to puberty  Late in childhood the hypothalamic- pituitary-gonadal axis is activated  Timing of puberty related to genetics, ethnicity and environmental factors  You will learn details of this in the Human Sexuality and Reproduction course this summer Tanner Stages The PA Life Physical Growth  Weight almost doubles  Height increases by 15-20%  Major organs double in size  Lymph tissue decreases  Muscle mass:  Doubles in boys  Decreases in girls  Growth spurt starts ~2yrs earlier in girls than boys  Starts ~1yr earlier than appearance breast/hair  Psychosocial development does not always mirror physical growth! Psychosocial Development: Early Adolescence 11-14yrs  Rapid physical growth and 2nd sex characteristics  Self image and esteem fluctuates markedly  Concerns about pubertal development  May be curious about sex, but prefer same sex groups; sexual orientation develops  Still concrete thinking, moving towards more abstract thinking as approach middle  Difficulty with imagining future  Unrealistic goals for adulthood  We are gonna be pro soccer players! >>>> Psychosocial Development: Middle Adolescence 15-17yrs  Rapid development subsides  Getting more comfortable with self  Often have INTENSE EMOTIONS!  No longer concrete thinkers >>”formal operational” abstract thinking  Omnipotence, “won’t happen to me” attitude  Self-centered thinking, identity experimentation  Dating, sex, peer pressure & conformity  Can be stressful for all parties involved! Psychosocial Development: Late Adolescence 18-21yrs  Less self-centered and more caring towards others  Shift from peer group relationships to individual  Dating more intimate  Abstract thinking develops, more realistic about future  Idealism and rigid wrong/right thinking Adolescents: Handle carefully and diplomatically!  Put biases aside  Avoid being authoritarian, intimidating or overly professional  Important to identify at-risk teens early  Care is focused on emotional, cognitive and psychosocial changes that affect behavior  Teens enrolled in primary care medical home receive preventative care:  Immunizations  Contraception  STI screening  Lowest rates for being insured and using these services  Social history must include sex, drugs, tobacco and alcohol  Remember ROS and social history are very important for adolescents Stages of adolescence Early Middle Late 11-14 15-17 18-21 Parents’ high medium low role Risk high lesser, but lower taking still high Peers’ less very high decreasing role Morbidity in Adolescents  As we know SDoH negatively impact our health  Poverty: US 2014 18% of families, notable ethnic and racial disparities, and in single mother households  Poor academic achievement, behavioral and mental health issues, risky behaviors  Majority of morbidity in adolescents is psychosocial and correlated with poverty  Pregnancy, STI, substance abuse, dropping out of school, depression, running away from home, violence, delinquency What is Morbidity? Common health problems of adolescents:  Acne  Scoliosis  Asthma  Slipped Capital Femoral  Diabetes  Sexually transmitted  Gyne and menstrual problems infections   Sports injuries High Blood pressure   Substance use disorders Infectious mononucleosis  Mental illnesses  Heat-related illnesses  Obesity  Road traffic injuries  Oral/dental health  Early pregnancy  Osgood-Schlatter disease  Violence Leading causes of deaths among adolescents aged 15–19 years:  Accidents  MVA NM 2016-2020 15-24 yrs:  Poisoning Accidents 599 people  Suicide 391 people Suicide (firearms) NM 2021 deaths by suicide  Homicide (firearms) age 10-24 yrs = 85 people NM 2019 suicide attempts  Cancer Grades 9-12 = 10.5%  Heart Disease CDC 2017  Confidentiality Confidentiality depends on: Exceptions (Conditional)  Level of maturity  Suicide  Intelligence  Homicide  Degree of  Sexual abuse independence  Physical abuse  Presence of chronic illness What is Confidentiality?  Example of Conditional vs. Unconditional Confidentiality “I want you to understand that when we talk about things that have to do with sex and drugs and your feelings, that it is confidential. This means that what we talk about is just between you and me and that other people, including your parents, will not find out about it unless you want them to know.” Conditional confidentiality typically includes a disclaimer: “Everything is confidential unless you tell me that you are going to hurt yourself or someone else, or you tell me something that by state law I have to report.”  Confidentiality: Medical Records  There are NO NM STATE STATUTES that protect confidential information in a child’s medical record from a parent who requests to review the medical record. Laws vary from state to state.  HIPAA: parents generally have access, except when a minor consents to care that does not require parent/guardian consent.  At University Hospital, 13-17 year old patients do not have portal access, nor do their parents.  Chart note may state “Confidential” Adolescents: Consent  Remember the principles of informed consent??  Adolescents can provide consent for certain services and medical care  Minor = less than 18 yrs old, consent given by parent/guardian  Emancipated Minor = minor has attained legal adulthood  Medical Emancipation = not a legal status, recognized in varying degrees in all states, can consent for all or certain medical care without care  Mature Minor doctrine = few states, can consent for routine, non-emergent medical care without parents, not a law Up To Date: Consent in Adolescent Health Care 2023  NM Statutes Annotated (NMSA) 32A-21-3. Emancipated minors; description: An emancipated minor is any person sixteen years of age or older who: A. has entered into a valid marriage, whether or not the marriage was terminated by dissolution; B. is on active duty with any of the armed forces of the United States of America; or C. has received a declaration of emancipation pursuant to the Emancipation of Minors Act [32A-21-1 to 32A-21-7NMSA 1978]. New Mexico Statutes Annotated 2015: Minors’ Consent NM Statutes Annotated (NMSA)  In addition, most states allow limited to full treatment without parental consent for sexually transmitted infections, pregnancy, contraception, mental health and substance abuse  New Mexico allows all of these without parental consent. NM Statutes Annotated (NMSA)  STI: exam and treatment for anyone  Pregnancy: Prenatal, delivery and postnatal care to a female minor  Contraception: family planning for anyone  Emergency: after making reasonable efforts to contact parents/guardian, anyone can stand in for parents and give consent  Mental Health (Including substance abuse):  14 yrs: verbal therapy (right to confidentiality and mental health record disclosure) and right to consent to psychotropic meds but parents will be notified NM Statutes Annotated (NMSA)  Certain minors > 14 yrs (homeless youth or parent of a child): unemancipated minor can consent to medically necessary health care  Clinical, rehab, physical, mental, behavioral  Must be living apart from parents/guardians Adolescent decision making: Jamie, a case study  At 14 years of age Jamie was diagnosed with renal failure.  Her condition was complicated  Repeated infections while on peritoneal dialysis  Several hospitalizations. Ethics Resource Center American Medical Association Jamie: Two years later  At age 16, Jamie received a kidney transplant.  Given cyclosporine to prevent rejection.  Six months after the transplant, there was evidence of rejection.  Her parents agree to return to hemodialysis.  Jamie could not remember a time when she had been well.  She is frightened about having to return to hemodialysis.  Jamie tells her provider that she does not want hemodialysis. Ethics Resource Center American Medical Association Jamie’s Predicament  She disagrees with her parents’ treatment decision.  She is not an emancipated minor.  Her parents are neither neglectful nor abusive, which are reasons that limit parental authority in clinical decision making.  Should 16-year-old Jamie be allowed to make a treatment decision with such grave consequences? Ethics Resource Center American Medical Association Respect for Jamie’s autonomy  Accepting Jamie’s current decision forecloses any future exercise of autonomy—she dies.  Protecting her right to future autonomy may mean exercising limited paternalism in the present– she lives.  Parent decision makers must protect a child’s future rights until the child attains full decision-making capacity.  What do you think? Ethics Resource Center American Medical Association Preserving Jamie’s future autonomy Moving forward:  Educate Jamie to gain her “informed consent.”  Understand her viewpoint- respond truthfully.  Negotiate about treatment options.  Attempt to persuade her of the benefits of continued treatment. Ethics Resource Center American Medical Association  Possible outcomes for Jamie 1. Persuasion succeeds and future treatment “succeeds.” 2. Persuasion succeeds but future treatment fails. 3. Persuasion fails.  If Jamie wants to discontinue treatment, the clinician must be confident that she is fully able to understand the consequences of her decision. Ethics Resource Center American Medical Association  Conclusions: Jamie’s case  Parents are most often the decision makers for their children.  Involving children, as they mature, in decisions about their medical care is an important part of good pediatric practice.  When adolescents’ preferences differ from those of their parents, the clinician must: o Be confident that the minor understands the condition and the consequences of the decision o Attempt to negotiate for treatment in chronic cases o Ethics Resource Center Respect the autonomy of the adolescent if persuasion or American Medical Association treatment fails Adolescent Well Visit  Bright Futures Pocket Guide has you covered!  Early Adolescent Visit (11-14yrs)  Middle Adolescent Visit (15-17yrs)  Late Adolescent Visit (18-21yrs)  Annual visits  Health Supervision with surveillance of development, Parent-youth interaction, Physical Exam with Vitals, Screenings, Immunizations, Anticipatory Guidance Adolescent Screening HEADSS: Adolescent Psychosocial History (HEADSSS, HEADSS+, HEADS-ED) 11 year old visit: History Vitals: Wt, Ht, BMI, BP Hearing Developmental Surveillance Psychosocial/Behavioral Assessment Physical Exam including SMR Immunizations: Covid, Influenza Tdap HPV Meningococcal Fasting Lipid Panel* Anticipatory Guidance Transitioning to Adult Care AAP Transitioning to Adult Care: Challenges Fear of a new health care system Anxiety (not knowing the adult clinicians, adult health care system, and logistical issues) Changing and/or different therapies recommended in adult health care Families’ fear that adult clinicians will not listen to and value their expertise Negative beliefs about adult health care Inadequate planning Inadequate preparation & support from clinicians on the transition process and adult model of care Not having seen clinician alone Youth and young adults less interested in health compared with broader life circumstances Adolescents’ age, sex, and race and/or ethnicity and their parents’ socioeconomic status System difficulties AAP  Pre-participation Sports Physical Exam: Maximizing safe participation! Identify medical problems with risks of life- threatening complications during participation (eg, hypertrophic cardiomyopathy) Identify conditions that require a treatment plan before or during participation (eg, hypertension) Identify and rehabilitate old musculoskeletal injuries Identify and treat conditions that interfere with performance (eg, exercise-induced bronchospasm) Remove unnecessary restrictions on participation Sports physical should focus on cardiovascular and musculoskeletal health.  Obtain thorough medical and family history  Menstrual history in females  Cardiovascular risk factors, previous injuries or surgeries  General physical exam  Heart, lungs, vision and hearing  Murmurs, wheezing, visual or hearing deficits  Focused musculoskeletal exam  Weakness, limited range of motion, previous injuries Let’s take a look at the Sport’s Form! Remember, we were all teenagers once… be kind!