HEALTH MAINTENANCE

FOR ADOLESCENT
By:
Dr. Sally Witwit
 Adolescent :
from 11 to 21 years old
3 of 4 adolescent engaged in risky behavior
Causes of death in adolescent
More than 70% of death in adolescent are due to:
1.Motor vehicle accident (31%)
2.Homicide (18%)
3.Suicide (12%)
4.Unintentional injuries (falls ,fires , drowning) (11%)
Adolescent health care visit
Definition: It is one of the best opportunities to impart
preventive medicine

Should be conducted yearly

It is acoordinated approach that include health risk
assesment, health guidance, prevention and acute and
chronic health care services delivery
Adolescent health care visit
Adolescent health care visit will cover 4 elements:
1. History & Physical examination
2. Screening
3. Immunization
4. Counseling
* Special emphasis is placed on screening
History & physical examination
History taking in adolescent differs slightly in:
1. Out line the appointment for both the youth & the
parents/ friend, partner to cover concerns followed by
having the adolescent alone for proper risk assessment
2. Discuss confidentiality with the patient
3. Normalize sexual practice
4. Display respect for the youth
5. Avoid assumption
6. Ask specific questions
7. Avoid medical jargon
8. Listen to response without interruption
9. Foster the patient-provider relationship & trust
10. Focus on determining risks such as:
Obesity, high blood pressure, substance use,
cardiovascular diseases & STI
Physical examination: should be complete
with attention paid to signs of abuse or self inflicted trauma

Lab. Testing & imaging should be based on

the individual’s risk assessment, history & physical exam.
Screening
It includes:
1. Obesity & eating disorders
2. Hypertension
3. Substance use
4. Depression
5. Suicide
6. Physical, sexual & emotional abuse
7. Learning or school problem
8. Sexual behavior
9. Hearing
10. Vision
11. Tuberculosis
12. Hyperlipidemia
13. Anemia
1. Obesity & eating disorders
• Adolescent should be screened for obesity yearly
• Adolescent Should be questioned about body image &
behaviors that may suggest eating disorders
• Excessive wt. loss or gain may be a sign of anxiety or
depression
• Obese adolescent should be referred to counseling &
behavioral intervention to promote improved weight status
Obesity is defined as BMI more than 95th percentile for age
& sex
Overweight is defined as BMI between the85th & 95th
percentile for age & sex
Underweight is defined as BMI less than the 5th percentile
for age & sex
2.Hypertension
Goals:
1. Identify primary vs secondary hypertension to reverse
the cause of secondary hypertension
2. Identify those who need antihypertensive treatment
3. Identify comorbid risk factors in those found to have
prehypertensive or hypertensive
The 2004 National High Blood Pressure Education
Program Working group definition are used to
classify blood pressure (BP) measurement in US
*BP percentile are based upon gender age &
height
*The systolic & diastolic BP are considered equal
with the higher value determining the BP category
• Both Syst. & Diast. BP below the 90th percentile are
considered normal
• Syst. &/or Diast BP above the 90th percentile but below
the 95th percentile are considered prehypertensive
• If either Syst. &/or Diast. BP is above th 95th percentile
are considered hypertensive, which is further classified
into (Stage 1) mild & (stage 2) severe
1.Mild hypertension: syst. &/or diast. BP between the 95th
percentile & 5 mm Hg above the 99th percentile
2.Severe hypertension: syst. &/or diast. BP 5mm Hg above
the 99th percentile
*Secondary hypertension is more likely in prepubertal
adolescent, stage 2 hypertension or those with diastolic
&/or nocturnal hypertension
*while primary hypertension is more likely in post pubertal,
stage 1 hypertension, over weight or have a significant
family history of hypertension
*Most adolescent especially those with secondary
hypertension may need to be referred to a specialist in
childhood hypertension or pediatric nephrologist
3. Substance Use
Youth should be asked about tobacco, drinking or illicit drug
use
If there is positive response to questions, screening tools
(CRAFFTquestionnaire) should be used for further
evaluation
C: car
R: relax
A: alone
F: forget
F: family, friend
T: trouble
If 2 or more Yes that means significant problem
4. Depression
Occurs in:
• 2,8% of children younger than 13y
• 5,6% of adolescent aged 13-18 y
It is recommended to ask each youth directly about
depression & suicide
The depression tools of screening (PHQ-2,PHQ-9
questionnaire, Beck depression inventory, Reynold’s
Adolescent Depression Screen,& Mood & Feeling
Questionnaire) are good start, but the result should be
interpreted along with other information, such as those from
parents or guardian
5. Suicide
• Suicide is the 3rd leading cause of death in children &
adolescents
• Ideation can occure in prepubertal age although attempts
& completion are rare (attempt & completion increase with
age)
• Female youth are more likely to have ideation, specefic
plan & attempt, but male are more likely to complete
suicide
• Provider should ask about risk factors & potentiating
factors for suicide
• Although potentiating factors do not contribute to suicide
directly , they interact with risk factors leading to more
risky behavior
Risk factors Potentiating factors

1. Psychiatric disorders 1. Access to means

2. Previous attempt 2. Alcohol or drug use
3. Family history of mood 3. Exposure to suicide
disorders or suicide 4. Social stress or
behavior isolation
4. History of physical or 5. Emotional or cognitive
sexual abuse factors
5. Exposure to violence
6.Physical, sexual & emotional abuse
• Abuse & violence are major cause of death & disability for
American children
• Victims& witnesses to abuse have both physical &
psychiatric sequele
• Violence is everywhere ,even in the safest place for youth
(school)
• Primary prevention of violence is the key for providers
seeing youth in their practice
Screening for violence
• Screening for violence & other risk factors should be
during all wellness exam
• If a youth discloses abuse, ensure safety for the youth
&report all cases of child abuse
• Screening for violence include both family assessment ,
environmental assessment & school performance:
1. Family assessment include: family funtion, stress or
coping mechanism& support system
2. Environmental assessment include: access to
weapons, namely guns
3. School performance : abrupt decline may be a sign of
bullying, depression, abuse or family stresses
Risk factors for violence & violence
related injuries
1. Previous history if fighting or violence related injuries
2. Access to firearm
3. Alcohol & drug use
4. Gang involvement
5. Exposure to domestic violence
6. Child abuse
7. Media violence
8. Violent discipline
7.Learning or school problems
• Not uncommon
• Provider should ask about difficulties at school including
academic performance & interaction with peers with
further evaluation for diagnosis & treatment for those at
risk
• Risk factors:
1. Poverty
2. Male sex
3. Presence of smoke
4. Being adopted
5. Having a two parent step family or other family
structure
8.Sexual behavior
• Middle adolescent (14-17y) have increasing sexual
interest
• As adolescent age there are higher rates of sexual activity
as well higher rates of STI
• In USA nearly half of new STI diagnosed in individuals
between (15-25y)
Counseling
1. Discuss their sexual orientation which is physical &/or
emotional attraction to the same &/or opposite gender
2. Discuss the gender identity which is person’s private
sense or subjective experience of their own gender i.e
one’s private sense of being a man or a woman
3. Do not assume individuals are heterosexual (10% of
adolescent female & 6% of adolescent male report
sexual encounters with the same sex)
4. Knowing the sexual orientation & gender identity will
allow the provider to appropriately counsel the youth
about safe sexual practice & refer who are struggling
with their gender identity & sexual orientation to
resourse for support
5. Without proper support & guidance & negative parental
reaction ,the (LGBTQ) teens may have increase risk of
personal violence, mental health issue, substance abuse
issue & risky sexual behavior
6. Provider should help all sort of youth through feelings &
behaviors to remain healthy & promote positive expression
of their sexuality
7. Provider should ask specific questions regarding their
sexual behavior &be assessed for the risk of STI by asking
about:
most recent activity, most recent partner, total number of
partners, condom use, contraception & when the female
want to conceive
8. The youth should differntiate condom use as STI & it’s
use as birth control method to increase compliance for
youth using another birth control method
9. Sexualy active adolescent should be screened for STI
including chlamydia, gonorrhea, HIV & syphlis
10. In USA it is recommended one –time universal HIV
screen in (15-65y), also should be screened for
trichomoniasis & hepatitis
11. About 90% of STI in adolescent is due to Chlamydia,
Trichomoniasis & HPV
12. Pap smear testing is recommended to be delayed until
the age of 21y
9.Hearing
• Ask about difficulty in understanding &
hearing in a variety of environment at each
annual visit
• If the patient indicate positive response, the
patient should be referred for audiometery
& appropriate follow up
10.Vision
• Vision test is recommended in 3 times:
1. Early (11-14y)
2. Middle (15-17y)
3. Late (18-21y)
• In years that the youth does not require vision testing , the
adolescent should be asked questions regarding vision
difficulties
11.Tuberculosis
• There is no indication for routine testing in children
entering daycare, school or attending camps in the
absence of risk factors
• Screening for T.B is indicated only in children at risk for
latent T.B infection or progression of latent infection
• Risk assessment for T.B is indicated at the first visit to
establish care & annually
• Risk factors for T.B include
1. Living in an endemic region
2. Another person in the household with positive
tuberculin test
3. Reactivation due to immunosuppressive condition or
medication
• Tuberculine skin test (TST)is recommended for screening
• Testing (TST) early after exposure may result in false
negative TST, so repeat testing is indicated (8-12) weeks
after exposure to infected individual
• Immigrants should be tested (8-12) weeks after
immigration,& should be retested (3-6) months later to
catch the false negative results, although if high risk,
immediate testing is indicated. (positive TST is over 10
mm)
• BCG vaccinated individuals may have (+ve) TST test
;therefore, Gamma interferon release assay may be used
to distinguish between latent T.B in which the assay will
be (+ve) & BCG vaccine in which the test will be(-ve)
12.Hyperlipidemia
• Bright future recommends universal
screening during the late adolescent (18-
21y) ,while NHLBI recommends universal
screening in early adolescent(9-11y) &
again in late adolescent (18-21y) with
selective screening in between for those at
high risk
*Risk factors:
1. Significant smoke exposure
2. Premature family history of coronary artery diseases
3. Parental history of dyslipidemia or total cholesterol over
240
4. Obesity
5. Childhood hypertension
6. Certain pediatric conditions associated with
atherosclerosis including: D.M type1&2, chronic kidney
diseases, cardiac transplant recipient, Kawasaki
disease, chronic inflammatory diseases, cancer
survivors, & being a homozygous or heterozygous for
familial hypercholesterolemia
13.Anemia
• Adolescent should be asked for the
risk of anemia by asking about their
eating habbits including vegan &
vegetarian patterns as well as
menstruation patterns to assess those
at risk
Immunization
• Adolescent should have their immunization reviewed at
every wellness exam &as necessary
• Student that are beginning college or youth in a detention
facility should be reviewed carefully
• At age 11 to 12y or (later for catch up) they should
receive:
1. Annual influenza vaccine (all ages)
2. Tdap
3. HPV(3 doses)
4. Meningococcal vaccine with booster at age 16-18y
• The following are recommended if not previously given:
1. Hepatitis B
2. Inactivated poliovirus
3. MMR
4. Varicella
5. Hepatitis A
• The following should be provided for specific high risk
population:
1. Pneumococcus
2. Hepatitis A
Anticipatory guidance( Counseling) for
adolescent
• Provider may not have enough time to discuss each point
at every exam , so the topics may be covered over the
course of multiple wellness exams
• Discuss the needs of the changing adolescent with the
parents at least once during early, middle, & late
adolescence
• Topics for discussion include:
1. Healthy dietary habits with discussion about healthy
weight, obesity, eating disorders & appropriate weight
loss behavior
2.Participating in regular exercise including 60 minutes of
exercise most days of the week, strengthening excercise &
limiting screen time 2 hours daily
3. Abstinence from tobacco, alcohol & other illicit
substances, including anabolic steroids
4. Responsible sexual behavior including abstinence or
proper protection & contraception
5. Use of bicycle& motorcycle helmets as well as cars seat
belts
6. Hearing loss prevention: wearing hearing protection
regularly
7. Discussion on bullying & how to deal with bullying
8. Refraining from online behaviors that may have negative
consequences including online relationship with strangers,
sharing personal information online or engaging in “sexting”
9. Routine dental care, including daily brushing/ flossing &
periodic dental visits
• 10. Using UV protection: children, adolescent & young
adults aged (10-24y) who have fair skin are
recommended to minimize their exposure to UV radiation.
Individuals highly exposed to sunlight should apply broad
–spectrum sunscreen with SPF 15 or higher daily &
thoroughly before going out & with SPF at least 30 if
inconsistent application
Health care maintenance for adolescent
aged 11-21y
Condition Recommendation
Screening
1. Obesity /eating BMI, screening
disorders questions
2.Hypertension Blood
pressure

3.Substance Screening
use questions
4. Depression/ Screening
suicide questions
5. Abuse ( physical, Screening
sexual,emotional) questions
6. Learning/ school Screening
problems questions
7. Sexual Screening questions ; STI testing
Conclusion
The adolescent health care maintenance visits is an
opportunity for evaluation of risks but also the adolescents
strength
The goal during the exam is to promote a healthy lifestyle &
healthy choices
Thank you