- Structure of Interview: Do an initial assessment with the parent and adolescent, focusing on chief complaint and history. Then speak with the adolescent alone. Start with a confidentiality statement, saying, “Everything is confidential unless I have a concern that you will harm yourself or someone else, or if someone is harming you.”
(HEADDDSSSV) Home | Who lives at home? Does everyone get along with each other? Do you feel safe at home? Do you eat meals with family? |
Education | What grade are you in? Have you ever been held back or skipped a grade? What is your best subject? What kinds of grades do you earn? What do you want to be when you grow up? |
Activities | What do you do in your spare time? Do you have a best friend? What is your best friend’s name? Do you have a job? How many hours each week do you work? How much TV/Video game screen time? How much physical activity? |
Drugs | Do you or your friends go to parties? Do they serve alcohol at these parties? Do you or your friends drink alcohol? Do you know anyone who smokes cigarettes? Do you smoke cigarettes? Do you know anyone who takes any other drugs? Have you tried any other drugs? |
Diet | Do you eat a balanced diet? How many servings of fruit/vegetables do you eat? Do you eat three meals a day? Are you happy with the way your body looks? Do you want to lose or gain weight? Have you ever tried restricting what you eat? Have you ever taken laxatives, diuretics, or diet pills to lose weight? |
Depression | Review SIGECAPS (changes in Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor retardation or agitation, Suicide) |
Suicide | How do you cope with stress? Have you ever thought of hurting yourself? Have you ever tried hurting yourself? |
Sex | Are you attracted to men, women, or both? Have you ever engaged in oral, vaginal, or anal intercourse? If so, do you use protection every time? What kind of protection? Have you ever had an STI? Have you ever been pregnant or been involved in a pregnancy? How many lifetime sexual partners have you had? How many partners have you had in the past 2 months? |
Safety | Do you wear a seat belt? Helmet during biking? Are there guns in the home? Do you feel safe at home? |
Violence | Is bullying a problem? Do you know anyone in a gang? Are you in a gang? Are there any guns at home? Have you ever been physically, emotionally, or sexually abused? Did you tell anyone about the abuse? |
Anticipatory guidance | Normal physical development Violence and injury prevention, bullying Healthy dietary habits and safe weight management Regular physical activity, limiting TV/Video games Responsible sexual behaviors, safe dating Avoidance of tobacco, alcohol, drugs |
Screening | HTN; hyperlipidemia; vision; anemia; obesity and eating disorders (weight and stature); substance abuse (CRAFFT)*; high-risk sexual behavior (cervical culture, urine leukocyte esterase); cervical cancer (Pap smear†); depression or suicide attempts/ ideation; physical, emotional, or sexual abuse; learning disabilities; school problems; tuberculosis screening |
Vaccine considerations** | Tdap, HPV, MCV, influenza, PPSV, HepA, HepB, IPV, MMR, varicella |
*CRAFFT is an acronym used to screen for alcohol abuse: Have you ever been in a car with someone who has been drinking? Do you drink in order to relax? Do you ever drink alone? Do you ever forget things after drinking? Have your family or friends encouraged you to stop drinking? Has drinking ever gotten you in trouble with the law? †Indications for Pap smear: Age 21 yr or older **see recommended immunization schedule for persons aged 7 to 18 years at www.cdc.gov/vaccines. | |
(Pediatr Clin North Am 1997;44(6):1525)
- Identify and diagnose conditions that preclude participation in specific activities.
- Develop treatment and rehabilitation plans for identified problems.
- Provide anticipatory guidance to prevent further injuries (especially un-rehabilitated injuries).
- Advise the athlete regarding sports restrictions if a condition exists.
- Fulfill legal, insurance, and school requirements.
- Past injuries or exclusion from sports for any reason, heat illness
- Loss of consciousness, memory loss, or concussion, traumatic numbness/tingling in extremities, seizures
- Unexplained syncope, presyncope, chest pain, discomfort, dyspnea, or fatigue with exercise
- Prior heart murmur or elevated blood pressure
- Asthma, allergies, exercised-induced bronchospasm, anaphylaxis
- Past surgeries and hospitalizations, chronic medical issues
- Current medications, vaccinations (including tetanus), supplements
- Weight increase or decrease and body image
- Menstrual history (young women)
(Circulation 2007;115(12):1643)
- Premature death or disability before 50 years of age caused by heart disease in any relative
- Specific knowledge of certain cardiac conditions in family members: Cardiomyopathies (hypertrophic), ion channelopathies (long QT syndrome), connective tissue disorders, hemoglobinopathies
- Vital signs looking for underweight or overweight; bradycardia or tachycardia
- Vision screen
- Skin, looking for contagious processes: HSV, MRSA, impetigo
- Cardiovascular Exam
- Heart murmur: Auscultate in both the supine and standing positions (or with the Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction (concerning for HOCM) that get louder when standing or with the Valsalva maneuver . Also screen for aortic stenosis and mitral valve prolapse.
- Femoral pulses to exclude aortic coarctation.
- Physical stigmata of Marfan syndrome or other connective tissue diseases
- BP (sitting position), preferably both arms.
- Heart murmur: Auscultate in both the supine and standing positions (or with the Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction (concerning for HOCM) that get louder when standing or with the Valsalva maneuver . Also screen for aortic stenosis and mitral valve prolapse.
- Abdomen: Evaluate for hepato- and splenomegaly
- GU exam (required for boys, but not for girls)
- Quick preparticipation orthopedic exam:
- General inspection: Look for asymmetry
- Neck exam: Cervical flexion and extension, rotation, lateral flexion (put ear to each shoulder) → exclusion from sports for further evaluation if limitation of ROM, weakness, or pain.
- Upper extremities: Full abduction of the arms—put the hands behind the neck and bring the elbows back as far as they can go (abduction and external rotation of the shoulder). Resist pressure while holding the arms in front of the body and at 90 degrees of abduction. Extend and flex the elbows with the arms at the side. Observe wrist pronation and supination. Spread the fingers, and tighten into a fist.
- Back: Inspect for scoliosis.
- Lower extremities: Toe raises, duck walk (assume squatting position → take four steps forward while squatting → turn 180 degrees and take four steps), hop five times as high as possible on each foot.
- General inspection: Look for asymmetry
Obesity | No exclusion; patient needs education and counseling (especially regarding heat illness, acclimatization, and hydration) |
Musculoskeletal sprain or strain | No automatic exclusion; further evaluation to assess stability in joint → rehabilitation → return to play |
Asthma | No automatic exclusion; patient needs plan to optimize pulmonary function, including an asthma action plan |
History of heat illness | No automatic exclusion; patient needs evaluation for underlying conditions and development of a prevention strategy |
Hypertension | No automatic exclusion; patient needs medical evaluation to continue if BP is >95th percentile for age/gender/height Partial exclusion if BP >5 mm Hg above 99th percentile on three occasions; avoid high-static sports, including weightlifting and power lifting until controlled |
Heart murmur | No automatic exclusion; if the murmur is innocent (does not indicate heart disease), full participation is permitted; otherwise, patient needs further evaluation |
Seizure disorder | No automatic exclusion; if seizures are not well controlled, individual assessment and treatment needed before clearance |
Carditis | Excluded because of risk of sudden death with exertion |
Fever | Excluded until fever resolves |
Skin infection (HSV, impetigo, Staphylococcus aureus, tinea) | Excluded during contagious period of illness if skin-to-skin contact or contact with mats (gymnastics) or other shared equipment occurs |
Organomegaly (eg, splenomegaly) | Excluded from any contact sports until full assessment is completed (especially if acutely enlarged) |
- For pelvic exam: Symptoms of vaginal or uterine infection, asymptomatic STI screening in sexually active young women, menstrual disorders, undiagnosed lower abdominal pain, sexual assault, suspected pelvic mass, request by the patient.
- For Pap smear: Cervical cancer screening should begin at age 21, not sooner, regardless of sexual history (Obstetrics and Gynecology 2009;114(6):1409).
- Considerations: Patients with physical or mental disability, abnormal anatomy, or physical immaturity with an intact hymen may be difficult to examine; consider exam under general anesthesia.
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- Explain each step of the exam as you proceed.
- Remember to wash your hands and use gloves.
- Have the patient empty the bladder before the exam.
- Place the draped patient in the supine position with her feet in ankle supports and have her slide her buttocks to the edge of the exam table and relax her legs into abduction.
- Abdomen (inspection, auscultation, palpation, percussion): Examine for skin changes, hernias, organomegaly, masses, tenderness.
- External genitalia
- Examine hair distribution (note sexual maturity rating), skin changes, labia minora and majora, clitoris, introitus, perineal body, Bartholin glands, Skene’s glands, and urethral meatus.
- Palpate for tenderness and adenopathy.
- Examine hair distribution (note sexual maturity rating), skin changes, labia minora and majora, clitoris, introitus, perineal body, Bartholin glands, Skene’s glands, and urethral meatus.
- Internal genitalia (speculum exam)
- Let the patient know the gel is cold; insert an index finger into the distal vagina and ask the patient to voluntarily contract against the finger (Kegel maneuver). Then insert a second finger (middle) and ask the patient to contract against the finger.
- Slowly insert an appropriately sized speculum into the vagina while applying downward pressure. Enter the speculum completely.
- Open the speculum to identify and examine the cervix and lock the speculum in place.
- Use two cotton-tip swabs to obtain a sample of vaginal discharge from the vaginal walls (document the volume, color, consistency, and any odor) for wet mounts and pH.
- Place a sample into 1 drop of saline on one slide and one drop of 10% KOH on another slide.
- Apply a swab to pH paper.
- Place a sample into 1 drop of saline on one slide and one drop of 10% KOH on another slide.
- Collect endocervical sample for cervical culture or NAAT for GC and Chlamydia.
- Collect endocervical cells for Pap smear by rotating the brush or spatula against the cervix. Place the sample in a Pap container, following the instructions specific to the Pap system being used.
- Upon completion of the exam, unlock the speculum and slowly back off the cervix. Close the blades as you remove the speculum completely.
- Let the patient know the gel is cold; insert an index finger into the distal vagina and ask the patient to voluntarily contract against the finger (Kegel maneuver). Then insert a second finger (middle) and ask the patient to contract against the finger.
- Bimanual exam
- Use your nondominant hand on the abdomen to sweep the pelvic organs downward while inserting the index and middle fingers of your dominant hand into the vagina to examine the vagina, cervix, uterus, adnexa, and cul de sac. Assess size, shape, symmetry, mobility, and position of the ovaries and uterus.
- Assess for cervical motion tenderness and adnexal and uterine tenderness. Attempt to distract the patient by palpating with the other hand on the abdomen, asking her if it hurts while simultaneously performing cervical motion and adnexal palpation. If the patient has cervical pain, despite the distraction maneuver, cervical motion tenderness (PID) should be considered.
- Use your nondominant hand on the abdomen to sweep the pelvic organs downward while inserting the index and middle fingers of your dominant hand into the vagina to examine the vagina, cervix, uterus, adnexa, and cul de sac. Assess size, shape, symmetry, mobility, and position of the ovaries and uterus.
- Abdomen (inspection, auscultation, palpation, percussion): Examine for skin changes, hernias, organomegaly, masses, tenderness.
- Complication: A small amount of bleeding after the Pap smear is normal.
- The normal cycle ranges from 21 to 35 days; menses lasts 3 to 7 days. The average blood loss is 30 to 40 mL per cycle. Menses are usually irregular for 1 to 2 years after menarche secondary to inconsistent ovulation (Pediatr Rev. 2007;28:175).
- Three phases of the menstrual cycle
- Follicular or proliferative phase: From the onset of menstrual flow to ovulation; the duration is 7 to 14 days. Begins with pulsatile GnRH release → release of LH and FSH → FSH causes ovarian follicle maturation → ↑ estradiol → proliferation of endometrium.
- Ovulation: Occurs midcycle; caused by LH surge from increased estradiol, ruptured ovarian follicle develops into a corpus luteum.
- Luteal or secretory phase: Starts after ovulation and ends with menses; the duration is 14 ± 2 days. The corpus luteum produces progesterone, which creates a secretory endometrium. Without fertilization, the corpus luteum involutes and production of progesterone and estradiol decreases → endometrial sloughing and GnRH release increases, leading to re-initiation of the cycle.
- Follicular or proliferative phase: From the onset of menstrual flow to ovulation; the duration is 7 to 14 days. Begins with pulsatile GnRH release → release of LH and FSH → FSH causes ovarian follicle maturation → ↑ estradiol → proliferation of endometrium.
- Dysmenorrhea is the most common gynecologic complaint of adolescent girls. It may be primary or secondary.
Etiology | Onset and Duration | Symptoms | Pelvic Exam | Treatment | |
|---|---|---|---|---|---|
Primary Dysmenorrhea (No pelvic pathology present) | |||||
Excessive amount of prostaglandin that binds to receptors in the myometrium, causing uterine contractions, hypoxia, and ischemia; also directly sensitizes pain receptors | Begins with the onset of flow or just prior and lasts 1–2 days. Does not start until 6–18 months after menarche when the cycle becomes ovulatory | Lower abdominal cramps radiating to the lower back and thighs; associated nausea, vomiting, diarrhea, and urinary frequency also caused by excess prostaglandins | Normal. May defer if never sexually active and does not use tampons and history is consistent with primary dysmenorrhea | Mild: NSAIDs prn Moderate to severe: Oral contraceptives with scheduled prostaglandin inhibitors (ibuprofen, naproxen, mefenamic acid) at onset of flow or pain | |
Secondary Dysmenorrhea (Underlying pathology present) | |||||
Infection | Often caused by an STI such as Chlamydia or gonorrhea | Recent onset of pelvic cramps | Pelvic cramps, excessive bleeding, intermenstrual spotting or vaginal discharge | Mucopurulent or purulent discharge from cervical os, cervical friability, cervical motion tenderness, adnexal tenderness, positive STI screening | Treat with appropriate antibiotic regimen (see section below) |
Endometriosis | Aberrant implants of endometrial tissue in the pelvis or abdomen | Usually starts more than 2 yrs after menarche | Pelvic pain; may occur intermenstrually | 2/3 of patients are tender on exam, especially during the luteal phase | Hormonal suppression by oral contraceptives for 3 months; if no relief, laparoscopy to confirm ± surgery if initial therapy is unsuccessful or disease is extensive |
Complication of pregnancy | Spontaneous abortion, ectopic pregnancy | Acute onset | Pelvic cramps associated with a delay in menses | ⊕ hCG, enlarged uterus or adnexal mass | Immediate gynecologic consult |
Congenital anomalies | Transverse vaginal septum, septate uterus, or cervical stenosis | Onset at menarche | Primary amenorrhea, pelvic cramps | An underlying congenital anomaly may be apparent; may require exam under anesthesia | Gynecologic consult; consider pelvic US or MRI, laparoscopy |
Intrauterine device (IUD) | Increased uterine contractions or due to pelvic infection | Onset after placement of IUD or acutely if caused by infection | Pelvic cramps, heavy menstrual bleeding, ± vaginal discharge | Normal or similar to infectious etiology (see above) | Prostaglandin inhibitors may be helpful; appropriate antibiotics and removal of IUD if infection is present |
Pelvic adhesions | Previous abdominal surgery or PID | Delayed onset after surgery or PID | Abdominal pain; may or ± association with menstrual cycle; possible alteration in bowel pattern | Variable | Surgery or may consider trial of TCAs |
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