Adolescent Health Maintenance Case File

Adolescent Health Maintenance Case File

Eugene C. Toy MD, Donald Briscoe, MD, FA  AFP, Bruce Britton, MD, Joel J. Heidelbaugh, MD, FA  AFP, FACG

Case 29

A 16-year-old adolescent girl presents for a routine well examination. She is a junior in high school and has no significant medical history. She plays on the school softball team and has a preparticipation clearance form for you to complete. She is accompanied by her mother who wants to know if her daughter should start having routine gynecologic examinations as part of her routine checkup. She states that the patient's last tetanus shot was at the age of 5. She received all of the routine childhood immunizations, including a complete hepatitis B series, and had chickenpox when she was 6 years old. The mother reports that there are no medical problems in the immediate family, but that one of the patient's cousins died at the age of 21 of a sudden cardiac death. When interviewed without the mother in the room, the patient reports to you that she is generally happy, she gets As and Bs in school, and has an active social life. She denies ever being involved in sexual activity, or tobacco or drug use. She says that she will have a "drink or two" at a party with her friends. On examination, her vital signs are normal. Examination of her head and neck, lungs, abdomen, skin, and musculoskeletal and nervous systems are normal. On cardiac auscultation, you hear a 2/6 systolic murmur that gets louder when you have her Valsalva. Peripheral pulses are strong and symmetric; there is good capillary refill and no sign of cyanosis.

⯈ What immunizations should be recommended at this visit?

⯈ At what age is it recommended to start routine Papanicolaou (Pap) smear screening?

⯈ What is the most common cause of sudden cardiac death in young athletes?

ANSWER TO CASE 29

Adolescent Health Maintenance

Summary: A healthy 16-year-old adolescent girl presents for a routine checkup and sports preparticipation examination. She is noted incidentally to have a heart murmur.

• Recommended immunizations: Tetanus-diphtheria-acellular pertussis (Tdap) booster, meningococcal vaccination, and catch up immunization for the human papillomavirus (HPV) vaccine series as well.
• Recommended age to start routine Pap smears: The American College of Obstetrics and Gynecology (ACOG) recommends that initial Pap smears are conducted at age 21. Paps are not indicated at ages younger than 21 regardless of sexual activity or pregnancy.
• Most common cause of sudden cardiac death in young athletes: Hypertrophic cardiomyopathy (HCM).

ANALYSIS

Objectives

1. Be familiar with evidence- and expert-based prevention guidelines for adolescents, including the Guidelines for Adolescent Preventive Services (GAPS) for screening examinations and counseling in adolescents.
2. Know the immunizations routinely recommended for adolescents and teenagers.
3. Know the components of and the rationale for performing sports preparticipation examinations.

Considerations

This is a healthy adolescent girl who comes in for a sports preparticipation physical examination. Required sports examinations provide an excellent opportunity for recommended health maintenance such as immunizations, screenings, risk reduction counseling, and general health education. Her history is unremarkable, and she has a 2/6 systolic murmur which increases with Valsalva. The history is the most important component to the sports physical examination. The focus should be on conditions that can lead to sudden cardiac death, which are usually cardiovascular, most commonly hypertrophic cardiomyopathy. Marfan syndrome is associated with aortic root dilation or dissection, hence stigmata of Marfan and family history is also important. The hallmark physical examination finding in HCM is a systolic murmur that decreases in intensity with the athlete in the supine position (increased ventricular filling, decreased obstruction). This contrasts with functional outflow murmurs common in athletes that increase in intensity upon lying down. The intensity of the HCM murmur increases with the Valsalva maneuver (decreased ventricular filling, increased obstruction). Any athlete who has a systolic murmur with an intensity of 3/6 or greater; a diastolic, holosystolic, or continuous murmur; or any other murmur that the examiner finds suspicious should be held from participation and referred to a cardiologist for evaluation. Most athletes with HCM are, however, asymptomatic. The individual in this case has only a grade 2/6 murmur, but it is worrisome that it increases in intensity with Valsalva. Most murmurs will decrease in intensity and duration with Valsalva. For this reason, this patient may benefit from referral to cardiology.

Approach To:

Adolescent Health

DEFINITIONS

GUIDELINES FOR ADOLESCENT PREVENTIVE SERVICES: A series of expert- and evidence-based recommendations from the American Medical Association (AMA) regarding the delivery of health services, promotion of well-being, screening for common conditions, and provision of immunizations for adolescents and young adults between the ages of 11 and 21 that is the framework for most adolescent preventive services guidelines.

HPV VACCINE: Immunizations against two, four, or nine high-risk strains of HPV are available. All three are recommended for adolescent girls and young women, ages 9 to 26. The four- and nine-strain HPV vaccines are recommended for males aged 9 to 26 to prevent anal cancer and genital warts. All three vaccines are a series of three injections over 6 months have been shown to be efficacious at reducing the incidence of genital warts and cervical cancer associated with the particular strains of HPV that are included in the vaccine.

CLINICAL APPROACH

Adolescence is a time of physical, emotional, and psychosocial changes. It is also a time of experimentation and, frequently, risk taking. Fortunately, adolescence is also a time of relatively good health for most. However, the choices made during adolescence can affect both the short- and long-term health of the patient. Addressing the unique health-care needs of adolescents can be difficult, as they may be more likely to present to the physician for acute illness than for health maintenance. For this reason, physicians should take the opportunity to consider age-appropriate health maintenance at each encounter with an adolescent and young adult.

Numerous issues can serve as barriers to providing effective care to adolescent patients; one of these is confidentiality. Many adolescents believe that physicians share any information provided with the parent. Consequently, they may not volunteer information, such as sexual activity or use of tobacco, alcohol, and drugs. One commonly used technique to address this is to take a history with the parent in the room, to allow the parent to present any concerns, then interview the patient alone, to allow the patient to speak confidentially with the doctor. Physicians who treat adolescent patients should have policies in place to ensure doctor-patient confidentiality while balancing the parent's right to be involved with the child's care. These policies should be discussed with and agreed to by the patient and parent in advance, so as to promote an honest, trusting, and therapeutic relationship.

The AMA has published in 1994 GAPS a series of recommendations regarding the delivery of health services, promotion of well-being, screening for common conditions, and provision of immunizations for adolescents and young adults between the ages of 11 and 21. These services are intended to be delivered as part of a series of annual health-care visits that address biomedical and psychosocial aspects of health and emphasize preventive services. Annual visits include counseling of parents

and guardians on adolescent health needs and risks in setting of rapid changes and increasing independence. These visits should include at least three complete physical examinations, one in early adolescence (age 11-14), one in middle adolescence (age 15-17), and one in late adolescence (age 18-21).

Other commonly cited guidelines for preventive services in adolescents include the United States Preventive Services Taskforce (USPSTF), American Academy of Pediatrics (AAP), Bright Futures, and the Advisory Committee on Immunization Practices (ACIP). There is good agreement among these guidelines on the following points:

• Following the ACIP guidelines on immunizations in adolescents
• Screening and counseling on prevention of injuries from accidents and violence
• Screening and counseling on prevention of cardiovascular disease (tobacco, obesity, hypertension, and cholesterol)
• Screening and counseling to reduce behavioral risk factors (drugs, alcohol, unsafe sexual practices)
• Promotion of oral and dental health

The GAPS recommends counseling for both parents and adolescents. It recommends that physicians provide guidance to parents on normal physical, sexual, and emotional development, signs of physical and emotional problems, parenting behaviors to promote health, and methods to help their child avoid harmful behaviors. Adolescent patients should receive counseling annually on their growth and development, injury prevention, healthy diet, exercise, and avoidance of harmful substances (alcohol, tobacco, drugs, anabolic steroids). Guidance should also emphasize responsible sexual behaviors, including abstinence and contraception, to reduce the risks of sexually transmitted diseases (STDs) and pregnancy.

GAPS recommends the routine screening for several medical, behavioral, and emotional conditions. All adolescents should be screened annually for hypertension, with further evaluation and treatment for those whose blood pressure is above the 90th percentile for their gender and age. All should be screened annually for eating disorders and obesity. All should also be screened for the use of tobacco (both cigarettes and smokeless tobacco), alcohol, and other substances of abuse. Routine drug toxicology screening, however, is not recommended. Lipid screening is recommended for those at above-average risk based on a personal history of comorbid conditions or a family history of hyperlipidemia, coronary artery disease, or other vascular diseases. Tuberculosis (TB) testing should be performed in those at high risk. These risks include having lived (or living) in a homeless shelter or in an area with a high prevalence of TB, having been (or being) incarcerated, having been exposed to active TB, and working in a health-care setting.

All adolescents should be asked about sexual behaviors, including sexual orientation, use of contraception, number of sexual partners, and history of pregnancy or STDs. Sexually active, symptomatic, and high-risk females should be screened for gonorrhea and Chlamydia by urine nucleic acid amplification. Cervical cancer screening should also be performed at 21 years, regardless of sexual activity. The 2012 ACOG screening guidelines state that screening for cervical cancer with Pap smears should begin at age 21. Symptomatic and high-risk sexually active males can be screened for presumptive gonorrhea and Chlamydia infections by urine nucleic acid amplification. The Centers for Disease Control and Prevention (CDC) recommends that all adolescents be screened for HIV. The USPSTF recommends HIV confidential screening in adolescent males and females with high-risk behaviors.

Other recommendations include screening all adolescents annually for depression and risk of suicide, with appropriate management or referral of those in need. All should also be questioned annually about emotional, physical, or sexual abuse. Every state mandates the reporting of suspected abuse of minors to the designated child welfare agency or child protective service. Difficulties at school or with learning should also be evaluated annually, with subsequent management to be coordinated with the school and parent/ guardian.

The adolescent health visit is also a time to ensure that the patient is appropriately immunized against preventable infections. In those who have received the recommended primary series, a tetanus-diphtheria (Td) booster is recommended at ages 11 to 12 and then, every 10 years thereafter. Because of the continued risk for infection with pertussis, a Tdap is recommended in place of one Td booster for adolescents and adults. Varicella vaccine should be offered to those who have not been vaccinated and who do not have a history of chickenpox. A measles-mumpsrubella (MMR) booster should be given if the patient did not receive a booster at ages 4 to 6. The hepatitis B series should be given to any adolescent who has not been previously immunized. Hepatitis A vaccine can be offered to those who live in areas with high infection rates, travel to high-risk areas, have chronic liver disease, or inject IV drugs, and to males who have sex with males. Routine meningococcal vaccination using a conjugate vaccine (MCV) is recommended at ages 11 to 12. If not previously vaccinated, vaccination before high school is advised. At age 16, patients should receive a meningococcal booster or before going into college dorms or the military barracks if only one dose given before age 16. Vaccination is also recommended for travelers to endemic areas, or the functionally I anatomically asplenic.

Three vaccines (Gardasil, Gardasil 9, and Cervarix) against high-risk strains of HPV are available. All three are recommended for adolescent girls and young women. Gardasil and Gardasil 9 are indicated for males aged 9 to 26 years. These vaccines are a series of three injections over 6 months that have been shown to be efficacious at reducing the incidence of cervical cancer associated with the particular strains of HPV that are included in the vaccine. The Gardasil vaccines have also been shown to effectively reduce the incidence of genital warts. It is preferred to provide HPV vaccination prior to the onset of sexual activity, so the series can be started in children as young as 9 years old, but it is routinely recommended for the ages of 11 to 12. It is also recommended for females and males aged 13 to 26 who have not completed the vaccine series. The HPV vaccine is also useful for those who have started sexual activity, as it may protect against strains of HPV to which the patient has not been exposed.

SPORTS PREPARTICIPATION EXAMINATION

A common reason for healthy adolescents to present to primary care physicians is for a preparticipation examination as a requirement to play a sport in school. The goal of these examinations is to attempt to identify conditions that may place a young athlete at risk during athletic participation. These conditions are primarily cardiac and orthopedic, but are not limited to these systems. A preparticipation examination allows the physician to provide the comprehensive health maintenance, including counseling, anticipatory guidance, screening, and vaccination, recommended in the GAPS. These encounters also serve to meet legal and insurance requirements of the school or school system.

The rate of sudden cardiac death in athletes is very low. Congenital cardiac anomalies are the most common etiology, with hypertrophic cardiomyopathy accounting for about one-third and anomalous coronary arteries for about one-fifth of cardiac anomalies. The history is the most important tool in screening for these abnormalities. All adolescents and their parents should be asked about personal history of exertional chest pain, dyspnea, syncope, history of heart murmurs, and family history of hypertrophic cardiomyopathy, other congenital cardiac abnormalities, or premature cardiac deaths. Other important historical information includes history of asthma or other pulmonary disorders, orthopedic injuries, heat-related illness, and absence of one of a paired organ (eg, single kidney, testicle, ovary, etc).

It is important to screen for eating disorders, as well as for a desire to change body weight, either for body image or for athletic purposes ( eg, "weight cutting" for wrestlers). Eating disorders are more common in female than male athletes. Female patients should be questioned about menstrual irregularities, as amenorrhea could signal anorexia and amenorrheic female athletes could be at risk for osteoporosis.

The examination should be thorough, but several aspects should be emphasized. Blood pressure should be measured and compared with age-and gender-appropriate norms. General appearance, specifically looking for signs of Marfan syndrome, should be noted. These signs, which include arachnodactyly, an arm span greater than height, pectus excavatum, tall-thin habitus, high-arched palate, and ocular lens subluxations, should prompt further evaluation, as persons with Marfan can have aortic abnormalities that predispose to rupture during sports. Auscultation of the heart should be performed, at minimum, in both the laying and standing positions. The murmur ofhypertrophic cardiomyopathy, while not always present, is best heard along the left sternal border and accentuates with activities that decrease cardiac preload and end-diastolic volume of the left ventricle. Therefore, standing or straining with a Valsalva maneuver would increase the murmur; conversely, squatting would be expected to decrease the murmur. Any adolescent with stigmata of Marfan syndrome, a murmur suggestive of hypertrophic cardiomyopathy, with a grade 3/6 or louder systolic murmur, or any diastolic murmur should be evaluated by a cardiologist prior to clearance for athletic participation.

No specific tests are recommended for universal screening of all athletes, although specific tests may be indicated based on history or physical examination findings. Echocardiography is the study of choice for the diagnosis of hypertrophic cardiomyopathy.

Participation in athletics or exercise should be encouraged. Absolute contraindications to all athletic participation are rare; more commonly, clearance to participate may be delayed for further evaluation of a suspected condition, rehabilitation of an injury, or recovery from an acute illness. In almost all cases, an adolescent should be able to find some athletic pursuit in which he/ she may participate.

CASE CORRELATION

• See also Cases 1 (Health Maintenance, Adult Male), 11 (Health Maintenance, Adult Female), and 18 (Health Maintenance, Geriatric).

COMPREHENSION QUESTIONS

29.1 A high school student is being seen for a sports preparticipation examination. Which of the following should prompt a referral to a cardiologist prior to clearance to participate in high school sports?

A. Grade 2/6 systolic murmur in an asymptomatic 16-year-old adolescent girl

B. Grade 1/6 diastolic murmur heard at the apex in a 17-year-old adolescent girl

C. Grade 2/ 6 systolic murmur in a 17 -year-old adolescent boy that is heard while lying down and that gets softer when standing

D. An asymptomatic 16-year-old whose grandfather died of a heart attack at age 72

29.2 A 15-year-old adolescent girl is brought in by her mother for a wellness clearance for sports participation at school. She would also like to discuss the addition of birth control. When the mother leaves the room, you learn that the girl is not sexually active but wants to start oral contraceptive pills (OCPs) because she has heard they help with acne and her friends have seen improvement. She does not drink alcohol or smoke and is in honors classes in the ninth grade. She plays on the junior varsity softball team and eats most days in the school cafeteria. Which of the following is recommended routinely in the GAPS and should be performed at this time?

A. Annual complete physical examinations between the ages of 11 and 21

B. Periodic screening for drug use with a urine drug toxicology test

C. Cholesterol testing

D. Annual screening for hypertension

29.3 A 17 -year-old adolescent boy reports that he has been sexually active with two female partners in the past year. He has used condoms "sometimes, but not always:' He is asymptomatic and has a normal physical examination. Which of the following tests would be recommended to screen him for gonorrhea and Chlamydia?

A. Urethral swab.

B. Serum antibodies to Neisseria gonorrhoeae and Chlamydia trachomatis.

C. Urine for nucleic acid amplification.

D. No screening is recommended.

ANSWERS

29.1 B. Any patient with a diastolic murmur, grade 3/6 or louder systolic murmur, murmur suggestive of hypertrophic cardiomyopathy, or signs of Marfan syndrome should be evaluated by a cardiologist prior to clearance to participate in athletics. The murmur of hypertrophic cardiomyopathy typically gets louder with maneuvers that reduce preload, such as the Valsalva maneuver or when standing.

29.2 D. GAPS recommends annual screening for hypertension by blood pressure measurement in all adolescents. Complete physical examinations are advised routinely, once during early adolescence, once in mid adolescence, and once in late adolescence, as well as more often when indicated. Lipid screening should be targeted to those who are at high risk based on personal or family history. Routine toxicology screening is not recommended.

29.3 C. Urine for nucleic acid amplification is recommended as screening for presumptive gonorrhea or Chlamydia in sexually active males. A urethral swab is only appropriate for diagnostic testing in a male who has a urethral discharge.

CLINICAL PEARLS

⯈ Adolescents tend to see physicians irregularly. Take the time at each visit, no matter what the reason for the visit, to review health maintenance issues.

⯈ Unvaccinated adolescents and teens should be offered vaccination opportunistically and routinely.

⯈ True contraindications to participation in all sports are rare. Almost everyone should be able to participate in some form of athletic activity.

REFERENCES

American Medical Association. Guidelines for Adolescent Preventive Services (GAPS): Recommendations Monograph. Chicago, IL: American Medical Association; 1997. 

Broder KR, Cortese MM, Iskander JK. Advisory Committee on Immunizations Practices (ACIP). Preventing tetanus, diphtheria and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines. MMWR Morb Mortal Wkly Rep. 2006 March 24;55:1-34. 

Centers for Disease Control and Prevention (CDC). FDA licensure of quadrivalent human papillomavirus vaccine (HPV4, Gardasil) for use in males and guidance from the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2010;59(20):630-632. 

Centers for Disease Control and Prevention (CDC). Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2013;62(RR-02):1-22. 

Giese EA, O'Connor FG, Brennan FH, Depenbrock PJ, Oriscello RG. The athleric preparticipation evaluation: cardiovascular assessment. Am Fam Physician. 2007;75(7):1008-1014. 

Ham P, Allen C. Adolescent health screening and counseling. Am Fam Physician. 2012 Dec 15;86(12):1109-1116. 

Marrazzo JM, Holmes KK. Sexually transmitted infections: overview and clinical approach. In: Kasper D, Fauci A, Hauser S, er al., eds. Harrison's Principles of Internal Medicine. 19th ed. New York, NY : McGraw-Hill; 2015. Available at: http://accessmedicine.mhmedical.com. Accessed May 25, 2015. 

Womack J. Give your sports physicals a performance boost.J Fam Pract. 2010;59(8):437-444.

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