Pediatric Primary Care (36 page)

5.  What is fluid intake?

6.  Does teen avoid public or school restrooms?

7.  Does schedule allow time to use bathroom?

8.  Have laxatives or stool softeners been tried? How often?

9.  Ask about other signs of thyroid disease, such as menstrual disorder, dry skin, brittle hair, lethargy, and weight gain.

D.   Teaching.

1.  Describe gastrocolic reflex (peristalsis of colon induced by entrance of food into empty stomach).

2.  Describe bowel function and need for fluid and fiber to keep stool moist and moving through GI tract.

E.   Physical exam for suspected constipation.

1.  Firm loops of bowel may be palpable on thin patients.

2.  Rectum is typically filled with hard stool.

3.  Passage of hard stool may cause anorectal pain or bleeding.

F.   Labs.

1.  Abdominal film may be needed in case of abdominal pain, after ruling out other systems as sources of pain.

2.  Make sure female patients are not pregnant before sending for X-ray.

G.   Treatment plan for constipation.

1.  Encourage drinking plenty of water.

2.  Help teen plan on how to add fiber to diet.

3.  Encourage good toilet habits, such as right after meals.

4.  Consider use of stool softener.

5.  In addition to the above, sitz baths may help anal fissure heal.

6.  Follow up in 1-2 weeks.

IV. SLEEP

A.   Teenagers need 9-10 hours of sleep per night. Most teens do not get it.

B.   Sleep history.

1.  Does teen feel rested or tired?

2.  What are concerns about sleep? Frequency? Duration?

3.  What are usual bedtimes and wake-up times?

4.  Are naps taken? If so, do they interfere with sleep later that night?

5.  Has family complained about teen's snoring?

6.  Does teen fall asleep in class? Other times?

7.  What are school hours?

8.  What are after-school activities?

9.  Does teen have job? How many hours?

10.  How many hours are spent on homework?

11.  Does teen care for child or have other household responsibilities?

12.  Is there family history of sleep disorders?

13.  Is teen depressed, sad, moody?

14.  Are stimulants (coffee, tea, soda, OTC medications, illicit drugs) used to stay awake longer?

15.  Does teen have TV, radio/stereo, computer, phone in bedroom? Are these in use when trying to go to sleep and delaying bedtime?

C.   Teaching.

1.  Insomnias are most frequent sleep disorder during adolescence.

2.  Insomnias involve problems falling asleep, staying asleep, waking too early.

3.  Delayed sleep phase syndrome is inability to fall asleep at appropriate time, but if left to fall asleep naturally would fall asleep late, get up late. These teens will be sleepy if awakened to attend school.

4.  Teens may be motivated to stay up late, sleep late. If teen can awaken by his/her own motivation but not for school, this may be form of school refusal.

5.  Insomnia may occur due to stress, anxiety, poor sleep habits.

6.  Excessive daytime sleepiness can be caused by chronic sleep deprivation, usually due to busy schedule.

7.  Sleep apnea may be associated with obesity; symptoms include snoring, apneic periods during sleep, nighttime waking, and daytime sleeping.

8.  Narcolepsy is uncommon disorder that has an onset of 10-25 years of age. Components include sleep attacks, catalepsy, sleep paralysis, and/or hallucinations. There is evidence of genetic component.

D.   Physical.

1.  Does teen appear alert?

2.  Does teen appear sad or depressed?

3.  Note blood pressure and pulse.

4.  Is teen obese?

5.  Is teen comfortable and able to breathe through both nostrils?

6.  Are tonsils enlarged?

E.   Lab.

1.  To rule out sleep apnea, consider sleep study if teen/family reports snoring, frequent wake ups, apneic periods, daytime sleep.

F.   Treatment plan.

1.  Have teen track sleep patterns for 1-2 weeks.

2.  Any question of depression needs assessment.

3.  Have teen/parent look at schedule and commitments. Are there ways to decrease workload for overloaded teen?

4.  Cut down on caffeine products, including OTC stimulants.

5.  Cut out nap time.

6.  Use bedroom for sleep only and put TV, computer, etc., elsewhere.

7.  Teach relaxation techniques.

8.  Identify stressors and write them down. If stressors are complex, consider counseling.

9.  Stick to regular schedule of bedtime and waking up.

10.  Encourage weight loss for obese teens.

11.  Refer teens with nasal breathing problems/enlarged tonsils to ENT specialist.

12.  Refer teens with difficult sleep problems, including those who do not do well with above plan, to sleep clinic.

V.  GROWTH AND DEVELOPMENT

A.   While some teens are able to state concerns, others may hope you will mention possible concerns for them, such as height, weight, pubertal development. Comfortable way to start such conversation may be “Some teens worry about being shorter (or taller, heavier, thinner) than their friends. I wonder if you have any concerns about this…”

B.   Use growth charts to help see progress over time, relate their parameters to their blood relatives or point out what future growth is likely.

C.   Tanner or sexual maturity rating (SMR) also may be reassuring.

D.   For development outside of expected range, evaluate for medical cause.

E.   Height.

1.  33-60% of adult bone growth occurs during adolescence.

2.  20-25% of final adult height occurs in puberty.

F.   Weight: 50% of ideal adult body weight is gained during adolescence.

G.   SMR: By middle adolescence most teens are in latter classes of Tanner or SMR scales. Spermarche occurs at about SMR 2.5. Menarche usually occurs at SMR 3 or 4. Using SMR can help teen to see where he/she is in puberty and what can be expected without having to compare himself/herself to friends.

1.  Menstrual history.

a.   Age at menarche?

b.   Frequency, duration, quantity of menstrual periods?

c.   Last menstrual period (LMP)?

d.   Dysmenorrhea and treatments used?

H.   Psychosocial developmental tasks.

1.  Increased independence from parents, inviting conflicts over control.

2.  Peer group involvement intensifies. Conformity with peer values. Less time for family. Teams, clubs, gangs may become important.

3.  Interest in dating, sexual experimentation. Preoccupation with romantic fantasy. Sexual orientation more evident to peers.

4.  Identity and individuality grow. Increased acceptance of body image, more established ego and sexual identity. Increased intellectual abilities, emotional feelings. Vocational ideas more realistic.

5.  Sense of omnipotence and immortality that may lead to high-risk behaviors.

6.  Improved ability with abstract thought.

VI. SOCIAL DEVELOPMENT

A.   Family.

1.  Who are family members living with teen?

2.  What is level of communication between members?

3.  What are supports? Conflicts?

4.  What are house rules? Who makes them?

5.  What are teen's responsibilities?

6.  Is there a curfew?

7.  Does teen drive family car? What supervision is given?

B.  School.

1.  What is teen's school performance? Any recent changes?

2.  What does teen like or dislike about school?

3.  How does teen relate to classmates? To teachers?

4.  Are there learning problems? Has teen been evaluated by school?