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An exercise in evaluating the adolescent patient

Maurer, Brian T. PA-C

Journal of the American Academy of PAs: November 2014 - Volume 27 - Issue 11 - p 58
doi: 10.1097/01.JAA.0000455658.65413.7a
The Art of Medicine
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Brian T. Maurer has practiced general pediatrics for more than 30 years. He is the author of Patients Are a Virtue and blogs at http://briantmaurer.wordpress.com. The author has disclosed no potential conflicts of interest, financial or otherwise.

Tanya Gregory, PhD, department editor

Figure

Figure

To sleep, perchance to Dream—aye, there's the rub.—Hamlet, Act 3, Scene 1

The PA student flags me down as I stride around the corner. Waiting outside the closed door of Exam Room #7 with chart in hand, she asks if she can present her patient. “What have you got?” I ask.

“A teenage boy who's complaining of headaches for the past month. He hasn't been able to sleep at night, either. He states he doesn't fall asleep until 5 a.m. Then he has to get up for school, and he's dog-tired for the rest of the day.”

“How old?”

The student stares at the boy's birth date and struggles momentarily with the calculation. “Seventeen,” she says.

“Any associated symptoms, any recent illness?” I ask.

The student shakes her head. “His vital signs are normal. So is the physical exam, as far as I can tell.”

I glance at the nursing note. Weight is recorded as 241 lb, a gain of 20 lb over the past 10 months. “Big kid,” I remark. The student nods her head. I rap on the door and we step across the threshold into the room.

I introduce myself to the boy and his mother. “I understand your son is having problems falling asleep at night,” I say.

The mother nods her head. “He's got headaches, too.”

“I see. When do you get headaches?” I ask the boy.

He shrugs his shoulders. “Every day,” he says.

“Where are they located?”

“In my head,” he says, placing a hand on his forehead.

I proceed to develop the history, focusing in on the P-Q-R-S-T pain mnemonic. He describes a tight bandlike distribution of pain around his head, typical for a tension headache.

“Tell me a bit more about your sleep habits,” I say.

“Nothing much to tell. I just can't fall asleep at night.”

“What are you doing when you can't fall asleep?”

“I play video games on my brother's PlayStation.”

“And where is your brother's PlayStation located?”

“He keeps it in his room.”

“So you play video games in your brother's bedroom?”

“No, I get the PlayStation and take it to my bedroom so he can sleep.”

I nod my head. “Do you have any other electronic devices in your bedroom?” I ask him.

He shakes his head.

“You've got a TV in your room,” his mother says.

“Ah, a TV,” I say. “That counts as an electronic device. Have you got a computer, a smartphone?”

“I've got a laptop—and my iPhone,” the boy says.

“And do you keep them in your bedroom as well?”

He nods his head.

“So you've got four electronic devices in your bedroom, right?”

The boy clears his throat and nods.

Over the ensuing 20 minutes, we learn that this 17-year-old boy participates in an online academic program from home. His mother works all day and doesn't come home until late evening. He doesn't interact with his stepfather; his 21-year-old unemployed brother camps out in the basement 24/7. After completing his assignments online, the boy watches TV for the remainder of the day, snacking when the urge arises. He takes no physical activity and participates in no social activities outside the home. Occasionally, he goes over to friends' homes to hang out. Several of his friends smoke marijuana, but he says he's never done drugs.

I point out these inconsistencies and suggest that he would fare much better if he were to establish a daily routine: rise at a regular hour, avoid grazing on snacks throughout the day, take regular aerobic exercise, establish a set bedtime, and remove all electronic devices from his bedroom.

“Take it one step at a time,” I tell him. “Map out a strategy. Come back in a couple of weeks and we'll see how you're doing, okay?”

I turn to the PA student. She appears crestfallen, mirroring the countenance of someone suffering from major depressive disorder.

“I had no idea,” she whispers.

“That's adolescent medicine for you,” I say. “Teasing out historical information takes time, and many times you won't have the luxury of spending it with them.”

“So what do you do?” the student asks.

I search my memory banks for a grain of wisdom. “Catch as catch can,” I say. “And when all else fails, bring them back the following week.”

© 2014 American Academy of Physician Assistants.