Handbook> OB > Teen Health

Pediatrics

Teen & Young Adult Health Center

Elective Number: 2429 (lottery)

Rotation Supervisor: Dr. Nancy McLaren

Duration: 2 weeks

Available: 3b, 4b, 5b, 6b, 7b, 8b, 9b, 10a, 11b, 12b & 14a

**possibly other rotations, but those would need to be arranged by contacting Dr. McLaren or Dyan directly**

Report to: Dyan Aretakis

Time to Report: Please email Dyan Aretakis week before to determine

Typical Day: 8:30 am - 5:15 pm

Place to Report: Teen & Young Adult Health Center, Corner Building

Suggested preparatory reading: Relevant chapters in Contraceptive Technology, 18th Edition; Hatcher, et al; Adolescent Health Care, 4th Edition, Neinstein, editor; Pediatric and Adolescent Gynecology, 4th Edition, Emans, et al, editor

Number of students per rotation: 1

Course Description: The Teen & Young Adult Health Center is a primary care center for teenagers and young adults.. It is a division of the Children’s Hospital. . It does general adolescent and young adult health care but also specializes in eating disorders , transgender health, contraption and does do Obstetric care . There is also a large focus on psychosocial health care.. The medical student rotating through the Teen Health Center should expect to see both males and females for a variety of visit types. Additionally, a psychosocial history is an important part of each visit.

GOAL 1: HEALTH SUPERVISION VISIT. Understand key strategies for scheduling and organizing health supervision care visits for adolescents.

OBJECTIVES
a. Describe the recommendations (outlined by the Bright Futures and GAPS guidelines) for the frequency and type of adolescent health care visits, and discuss the rationale behind these recommendations.
b. Discuss how to organize the adolescent visit (e.g., individualization according to the adolescent's developmental level, cultural background and family characteristics).
c. Describe ways to make the office environment suitable to serving this age group and providing education and counseling both to adolescents and their parents (e.g., separate waiting rooms, extended hours, patient education methods).

LEARNING ACTIVITIES
1. General clinics at the Teen and Young Adult Health Center
2. Assigned and independent reading

GOAL 2: HISTORY AND PHYSICAL EXAMINATION. Understand the process and content of an effective adolescent history and physical examination, including issues related to confidentiality and privacy.

OBJECTIVES
a. Obtain and interpret a detailed history from the adolescent assessing current health concerns, social history and behaviors that may affect health.
b. Obtain and interpret a history from the adolescent's parent(s) including: concerns about the adolescent's health, past medical history, family history, social history, needs for anticipatory guidance, etc.
c. Describe how to use questionnaires (e.g., Initial and Periodic Adolescent Preventive Services Visit Forms developed as an adjunct to GAPS), trigger questions (e.g., from Bright Futures), and organized interview techniques (e.g., H.E.A.D.S.S.).
d. Demonstrate how to approach and perform the physical examination of male and female adolescents and young adults.
e. Perform and interpret screening physical examinations for problems such as:
1. Cardiovascular disease or risk (hypertension, mitral valve prolapse, cardiac arrhythmia, obesity)
2. Dental and periodontal disease
3. Musculoskeletal problems (e.g., Osgood Schlatter disease, scoliosis, injury, sport fitness)
4. Sexual maturity rating/Tanner staging (pubic hair, genital development, breast development)
5. Skin problems (acne, tinea, etc)
6. Sexually transmitted diseases (pelvic exam, male reproductive health screening)
f. Discuss consent and confidentiality and their relationship to treating the adolescent patient as well as involvement of parents in providing care to adolescents.
g. Discuss specific times when confidentiality should be abrogated (e.g. life threatening situations, illegal situations, compromise in adolescent's health, danger to the patient, adolescent's inability to handle the problem him/herself).

LEARNING ACTIVITIES
1. General clinics at the Teen and Young Adult Health Center
2. Communications videos, and independent readings

GOAL 3: NORMAL VERSUS ABNORMAL. Understand normal adolescent behavior, growth and development and be able to recognize deviations from the norm.

OBJECTIVES:
a. Describe normal patterns of physical growth and pubertal development during adolescence and apply this knowledge to evaluation of variations in growth patterns and pubertal changes.
b. Describe normal psychosocial development in adolescents and apply this knowledge to evaluation of "behavior problems" in adolescents.
c. Describe normal musculoskeletal and cardiovascular status in adolescents and apply this knowledge to evaluation of adolescents for participation in a variety of sports activities.

LEARNING ACTIVITIES
1. General clinics at the Teen and Young Adult health Center
2. Lectures

GOAL 4: COMMON CONDITIONS NOT REFERRED. Understand how to diagnose and manage common conditions in adolescents which generally do not require referral.

OBJECTIVES
a. Recognize the presenting symptoms, diagnose, describe the pathophysiology, and manage these conditions:
1. Abdominal: chronic abdominal pain.
2. Cardiovascular: risk factors, hyperlipidemia, hypertension, chest pain, syncope.
3. Dermatologic: acne, viral exanthems, dermatoses, eczema.
4. Genitourinary: dysmenorrhea, mild dysfunctional uterine bleeding, irregular menses, vaginitis, cervicitis, STDs, uncomplicated pelvic inflammatory disease (PID), epididymitis, UTI, pregnancy diagnosis, mildly abnormal pap smears.
5. Musculoskeletal: kyphosis, scoliosis < 20o, Osgood-Schlatter Disease, chondromalacia patella.
6. Neuropsychiatric: headaches, dizziness, school phobia and truancy, attention deficit disorder.
7. Pulmonary: asthma, mild and moderate.
8. Endocrinology, irregular menses, polycystic ovary syndrome.
9. Other: obesity, breast fibroadenoma, gynecomastia

LEARNING ACTIVITIES
1. General clinics at the Teen and Young Adult Health Center.
2. Lectures
3. Assigned and independent reading

GOAL 5: CONDITIONS GENERALLY REFERRED. Understand how to recognize, manage, and refer adolescent conditions which generally require consultation or referral.

OBJECTIVES
a. Identify, provide initial evaluation and management, and refer appropriately these conditions:
1. Cardiovascular: mitral valve prolapse, pathologic heart murmurs.
2. Dermatologic: cystic or nodular acne.
3. Endocrinology: hyper or hypothyroidism, unusual hirsutism or virilism, abnormal growth, delayed puberty, unstable diabetes mellitus.
4. Genitourinary: ectopic pregnancy and abortion, primary and secondary amenorrhea of undetermined etiology, severe dysfunctional uterine bleeding, ovarian cysts and tumors, testicular torsion, scrotal mass, varicocele, hydrocele, HIV, GU trauma, Bartholin's abscess, complicated PID.
5. Musculoskeletal: patella dislocation, scoliosis > 20o, bone tumors
6. Neuropsychiatric:, ,some substance abuse including anabolic steroids, psychosis, conduct disorders
7. Other: breast masses.
b. Maintain a supportive, primary care relationship with adolescents who are referred for management of specific disorders to a specialty consultant.

LEARNING ACTIVITIES
1. Teen and Young Adult health Cetner
2. Lectures
3. Assigned and independent reading

GOAL 6: SCREENING LABORATORY. Understand the principles of and be able to perform standard laboratory procedures for adolescent health screening.

OBJECTIVES
a. Discuss rationale, timing, office methods and interpretation of results for the following screening procedures:
1. Sexually transmitted diseases (GC, chlamydia, syphilis, HIV, HPV, trichomonas, HSV)
2. Cervical dysplasia and mildly abnormal Pap smear
3. Hepatitis
4. Anemia
5. Hyperlipidemia
6. Tuberculosis
7. Hearing screening
8. Vision screening
9. Glucose intolerance/Diabetes Mellitus

LEARNING ACTIVITIES
1. General clinics at Teen and Young Adult health Center

GOAL 7: IMMUNIZATIONS. Understand health supervision for adolescents related to immunizations.

OBJECTIVES
Assessment and screening
a. Describe the routine immunizations needed in this age period and their rationale.
b. Describe risk factors and indications for special vaccines in this age group (e.g., influenza).
c. Describe effective routines for gathering immunization information during visits for illness and health supervision care.
d. Identify the immunization status of the adolescent.
Health promotion/disease prevention
e. Provide routine immunizations and related counseling including contraindications, common side effects and informed consent.
f. Discuss strategies to improve vaccination rates among teens.

LEARNING ACTIVITIES
1. General clinics at the Teen and Young Adult Health Center
2. Assigned and independent reading

GOAL 8: SPORTS MEDICINE. Understand health supervision related to activities and sports for adolescents.

OBJECTIVES
Assessment and screening
a. Evaluate sports readiness for healthy children and children with chronic disease or disabilities.
b. Recognize medical conditions which affect sports participation.
c. Evaluate the psychological readiness of adolescents for competition.
d. Recognize and manage heat illness/dehydration in sports activities.
e. Recognize the use of steroids and other performance enhancing drugs.
Health promotion/disease prevention
f. Describe the need for and the benefits of physical fitness for adolescents.
g. Recognize key concepts about adolescent exercise physiology and training including aerobic, anaerobic, strength training and flexibility.
h. Identify age appropriate activities for adolescents.
i. Counsel parents about adolescents’ emotional response to competition and effects of competition self esteem.
j. Recognize components of a safety-conscious sports program; and counsel parent and adolescent about sports-related safety (e.g. dental and eye safety).
Management of common problems
k. Recognize and manage adolescents with these problems in the context of the health supervision visit:
1. mild injuries such as sprains, strains, contusions, dental trauma, etc.
2. adolescents pressured to perform/excel
l. Discuss the "side-line" evaluation and management of sports injuries.
m. Recognize "side-line/office return to play" criteria.

LEARNING ACTIVITIES
1. Work in the office of sports medicine specialists
2. “The Musculoskeletal Evaluation” DVD, assigned and independent reading
3. Performing pre-participation sports physicals in clinic
4. Lectures

GOAL 9: NUTRITION AND EATING DISORDERS. Understand health supervision for adolescents related to healthy diet and eating patterns.

OBJECTIVES
Assessment and screening
a. Use screening tools to evaluate growth and measure weight and height; plot on standardized growth charts; calculate the body mass index (BMI).
b. Obtain a nutritional history to assess dietary patterns; use trigger questions to further assess risk for obesity, poor nutrition and eating disorders (e.g., assess television watching time, conformity with food fads, adolescent special diets, perception of body image, use of laxatives).
c. Obtain a family medical and psychosocial history and use it with the dietary history to assess risk for obesity and/or other medical problems (hypertension, hyperlipidemia).
d. Perform a physical examination focusing on findings that could indicate an eating disorder (malnutrition, bradycardia, hypothermia, lanugo-type hair over face/upper trunk, orthostatic pulse and blood pressure changes, etc.).
Health promotion and disease prevention
e. Describe a healthy adolescent diet.
f. Recognize common deficiencies in the diet of an adolescent (low iron, low calcium) and their consequences.
g. Describe the importance of routine physical activity and suggest the types that should be included in adolescents' daily activities. [See GOAL 4.49 Physical Activity (Adolescent)]
h. Discuss the relationships between adequate weight, overall health, normal physical development, and physiologic functioning.
i. Counsel adolescents to recognize risks for eating disorders and ways to overcome them.
j. Recognize when adolescents cannot resolve diet/eating problems on their own and assist them in finding solutions that may include outside counseling or involving parents.
Common problems
k. Manage these common problems:
1. A mildly overweight adolescent
2. An adolescent female with inadequate calcium intake
3. An adolescent with iron deficiency anemia
4. An adolescent at risk for cardiovascular disease
5. An adolescent with a tendency to exercise or diet in excess
6. An adolescent with signs of anorexia or bulimia

LEARNING ACTIVITIES
1. General clinics at the Teen and Young Adult Health Center
2. Meet with nutritionist
3. Assigned and independent reading
4. Lectures

GOAL 10: PSYCHOSOCIAL DEVELOPMENT. Understand health supervision related to the psychosocial development of adolescents.

OBJECTIVES
Assessment and screening
a. Identify the stages of psychosocial development in adolescence and the ages at which they usually occur.
b. Explore the adolescent's perspective on relationships with families and peers using organized interview technique (H.E.A.D.S.S) or trigger questions (Bright Futures, GAPS).
c. Identify adolescents' concerns regarding their appearance, self-esteem, and ability to handle stress.
d. Recognize adolescents at risk for being victims of excessive peer pressure.
e. Recognize adolescents in conflict with their families and parents having serious difficulties parenting their teenager.
f. Recognize the importance of the covariation of behaviors (e.g. alcohol and sexual behavior) and consider the relationship between individual problems or concerns and other conditions.
g. Become familiar with risk-taking behaviors and perform comprehensive risk assessment of an adolescent.
h. Become comfortable with using the CRAFFT screening tool for substance use.
Health promotion/disease prevention
i. Counsel adolescents about physical and emotional changes which are part of normal adolescent development.
j. Counsel families about normal adolescent psychosocial development and provide guidance about ways to help the teen develop appropriate independence, self esteem, and social competency.
k. Present strategies to both parents and adolescents to assist them in maintaining their positive relationship.
l. Counsel adolescents that peer pressure exists, but should not rule their lives and present strategies to help them deal with it.
m. Encourage adolescents to accept, manage and express feelings in a positive way to promote good mental and physical health.
Common problems
m. Recognize and manage or know when to refer these common problems:
1. Adolescent having disagreements with his/her parents
2. Adolescent concerned about peer pressure
3. Adolescent scared of his/her feelings
4. Adolescent with somatic complaints
5. Parent(s) in need of additional guidance about raising teens

LEARNING ACTIVITIES
1. General clinics at the Teen and Young Adult Health Center


GOAL 12: INJURY PREVENTION. Understand health supervision related to adolescent injuries.

OBJECTIVES
Assessment and screening
a. List and explain the four major risk factors associated with injuries to adolescents (use of substances, failure to use safety devices, access to firearms, participation in sports).
b. Describe how developmental and behavioral stages of adolescence and psychosocial factors relate to risks for injury, violence and abuse.
c. Use trigger questions to determine the potential risk for intentional and unintentional injury.
Health promotion/disease prevention
d. Provide injury counseling which is tailored to adolescents, based on their particular risks (exposures) and level of development (early, middle and late adolescence).
e. Recognize adolescents' perceptions of what impresses their peers as a potential barrier to compliance with anticipatory guidance.
f. Counsel adolescents about dangerous behavior in a highly focused manner, including discussion of important factors known to increase risk (e.g., when counseling about safe driving, target: drunk driving, wearing restraints, speeding, and driving under hazardous conditions).
g. Present anticipatory guidance to adolescents in a manner which enhances their trust and encourages a realistic sense of personal vulnerability (e.g., attach behavior to the occurrence of specific negative outcomes).
h. Counsel effectively on these topics:
1. Firearms
2. Substance abuse
3. Use of safety devices (seat belts, helmets, flotation devices for water activities)
4. Peer violence and abuse
Common problems
i. Manage these common problems:
1. Simple lacerations, contusions and musculoskeletal trauma from mild injuries
2. Counsel about risk reduction when seeing an adolescent following minor injury related to risky behaviors


LEARNING ACTIVITIES

1. General clinics at the Teen and Young Adult Helath
2. Emergency Room

GOAL 13: SEXUALITY. Understand health supervision for adolescents related to sexual issues.

OBJECTIVES
Assessment and screening
a. Assess the adolescent's knowledge of sexual identity, sexual activity, reproduction, and transmission of disease, and relate this to the three stages of adolescence.
b. Gather information about the adolescent's sexual development and sexuality using organized interview techniques (H.E.A.D.S.S) or trigger questions (GAPS, Bright Futures).
c. Obtain and interpret a sexual history including such topics as menstrual history, nocturnal emissions, sexual activity, STD's, AIDS, contraception, homosexuality, abstinence, pregnancy, and safe sex.
d. Perform and interpret an examination for sexual maturity rating, using standard descriptions for rating.
e. Perform and interpret an examination for STD's, cervical dysplasia, pregnancy, HIV if indicated.
f. Determine adolescents' risks for:
1. STDs and HIV infection
2. Pregnancy
3. Exploitation
4. Past or present sexual abuse
Health promotion/disease prevention
g. Be aware of cultural influences on adolescent sexual attitudes. Counsel adolescents on areas that influence their sexual behavior, such as:
1. Information about sexual functioning and reproduction
2. Attitudes about sexual behavior for self and others
3. Feelings about one's sexuality
4. Skills for communicating about sexual issues
h. Counsel adolescents about avoiding exploitation, date rape and other situations where they can be vulnerable.
i. Counsel adolescents to anticipate risky situations in advance (e.g. dating people who are considerably older and more sexually experienced) and present strategies to handle such situations.
j. Counsel adolescents that sexuality education is a life long process of acquiring information and forming attitudes, beliefs and values about identity, relationships and intimacy.

k. Provide demonstrations and instruction on:
1. Using condoms
2. Contraception(s)
3. Prevention of disease transmission

l. Assist the adolescent in developing strategies to promote safe sexual activities.
Common problems

m. Recognize, manage and know when to refer the following common problems:
1. Adolescent with a vaginal/urethral discharge
2. Adolescent with missed or irregular menstrual periods
3. Adolescent concerned about isosexual attraction
4. Adolescent with concerns about HIV
5. Adolescent who is pregnant

LEARNING ACTIVITIES
1. General clinic at Teen and Young Adult health

GOAL 14: TOBACCO USE. Understand health supervision for adolescents related to tobacco use.

OBJECTIVES
Assessment and screening
a. Assess the adolescent's use of tobacco (cigarettes and/or smokeless tobacco) and attitudes about starting or quitting.
b. Document other risk factors associated with tobacco use (e.g., family members who smoke, peers or friends who smoke, early sexual involvement, limited coping resources, overestimation of smoking prevalence).
c. Perform a physical examination, looking for physical signs of smoking (e.g., yellow staining on hands) or tobacco effects (exacerbation of asthma, abnormality of gums due to tobacco chewing).
Health promotion and disease prevention
d. Assess adolescents' knowledge about the effects on the body of smoking or passive exposure to tobacco.
e. Counsel adolescents on the positive health and social benefits associated with avoidance of tobacco use or passive exposure.
f. Provide positive reinforcement to teens who don't use tobacco or who quit using it.
g. Counsel adolescents on the risks of tobacco use, including social disadvantages, reduction of athletic ability, staining of teeth and associated health risks.
h. Describe strategies to resist tobacco products.
i. Be aware of smoking prevention programs taught in school.
Common problems
j. Counsel adolescents who use tobacco products about strategies for quitting, including how to find out about and or enroll in smoking cessation programs in the community.
k. Recognize and manage adolescents with asthma who experience exacerbations because of tobacco use.

GOAL 16: DEPRESSION AND SUICIDE. Understand health supervision for adolescents related to depression and suicide.

OBJECTIVES
Assessment and screening
a. Perform and interpret screening for depression and risk of suicide, including:
1. Review of systems to screen for associated somatic complaints associated with depression (e.g., headache, chest pain, abdominal pain, lethargy, syncope).
2. Behavioral history to screen for behaviors associated with depression (e.g., school failure, truancy, sexual acting out, delinquent acts, substance abuse, other mental health/psychiatric conditions).
3. Social history to assess parental mental health
b. Use trigger questions (e.g., GAPS, Bright Futures) to identify teens at risk for suicide or at risk for adverse consequences related to depression.
c. Perform extended assessments on adolescents at risk for depression to determine:
1. Level of depression
2. Health and functional consequences of depression
3. Social support system
d. Perform extended assessments on adolescents at risk for suicide (e.g., frequent suicidal thoughts, planning suicide, written suicide note).
e. Recognize different levels of depression and suicide risks and discuss appropriate disposition including supportive therapy, psychiatric evaluation, judicious use of medications and/or immediate hospitalization with psychiatric evaluation.
f. Recognize and manage or refer the following common problems:
1. Adolescent who is mildly depressed without suicidal ideation
2. Adolescent who has experienced recent death of a parent, sibling, neighbor or classmate

LEARNING ACTIVITIES
1. General clinic at Teen and Young Adult health
2. Assigned and independent readings


GOAL 17: SERVING THE MEDICALLY UNDERSERVED POPULATION: Understand how to provide acute and ongoing support to patients who are homeless or don’t have a primary medical home.

OBJECTIVES
Assessment and Screening:
a. Identify adolescents at risk for homelessness.
b. Identify common health problems in the homeless adolescent (skin and respiratory infections, STD’s, substance abuse, nutritional problems).
c. Identify adolescents who have had inadequate primary care due to financial reasons or lack of access
d. Be able to empower adolescents to obtain and utilize appropriate medical care
Health promotion and disease prevention:
e. Become aware of resources for homeless or near-homeless in the community.
f. Be able to interact effectively with homeless adolescents who tend to mistrust authority figures.
g. Know how to approach issues in providing health care in less-equipped outreach sites.

GOAL 18. LEGAL ISSUES: Understand the law as it applies to adolescent health.

OBJECTIVES
a. Understand that laws governing adolescent health are an amalgam of U.S. Constitution, federal and state statutes, court or judge-made law (common law), as well as federal, state, local and institutional regulations.
b. Be able to apply the law using clinical scenarios.
c. Recognize when one should seek expert legal opinion from the participant’s setting, governing institution, local community and state.
d. Know the definition of emancipated minor and who can consent to care under the Texas Family Code.
e. Understand the concept of mature minor.

LEARNING ACTIVITIES
1. General clinics at the Center for Adolescent Health, adolescent off-site clinics, resident’s continuity clinic, East Austin Clinic
2. Review consent forms available at People’s Community Clinic; know when and how to utilize each form
3. Independent and assigned readings
4. Lectures

GOAL 19. ADVOCACY. Understand ways physicians can serve to promote adolescent health in the community

OBJECTIVES
Assessment and Screening
a. Be aware of negative media influences on adolescent health (television, magazines, billboards)
b. Be aware of negative environmental influences on families (financial stresses, lack of parental availability)

Health promotion/disease prevention
a. Know what community efforts and campaigns are underway to improve adolescent health and the physician’s role in reinforcing them with individual patients or by actively participating in them(substance abuse awareness, pregnancy prevention, mentoring)
b. Know what physician and health department organizations are doing to improve adolescent health (substance abuse prevention, bicycle helmets)
c. Know about local youth-serving agencies that are involved in adolescent health issues.
Common problems
a. Provide knowledgeable information and leadership to organizations or communities that are dealing with problematic adolescent health issues.
b. Be able to assess which programs are effective and developmentally appropriate.
c. Be able to participate in outreach efforts.

PEDIATRIC COMPETENCIES IN BRIEF: ADOLESCENT MEDICINE

GOAL 3.48: Pediatric Competencies in Brief (Adolescent). Demonstrate high standards of professional competence while working with adolescents. [For details see Pediatric Competencies]

3.48.1. Competency 1. Patient Care. Provide family centered patient care that is developmentally and age appropriate, compassionate, and effective for the treatment of health problems and the promotion of health.
3.48.1.1. Use a logical and appropriate clinical approach to the care of adolescents,applying principles of evidence-based decision-making and problem solving.
3.48.1.2. Provide sensitive support to adolescents and their families in all clinical settings (outpatient, continuity, adolescent clinic, school and community settings, mental health services, inpatient hospital services)

3.48.2. Competency 2. Medical Knowledge. Understand the scope of established and evolving biomedical, clinical, epidemiological and social-behavioral knowledge needed by a pediatrician; demonstrate the ability to acquire, critically interpret and apply this knowledge in patient care.
3.48.2.1. Demonstrate a commitment to acquiring the base of knowledge needed for care of adolescents.
3.48.2.2. Know and/or access medical information efficiently, evaluate it critically, and apply it to adolescent care appropriately.