Kimberly is a 15 year old high school sophomore who comes to the office complaining of a sore throat. Her mom is afraid that she might have mononucleosis. Kimberly's chart reveals that her last visit to the office was four years ago. Mom explains that Kim is in good health...hasn't had anything more than a cold in the past four years.
John is a big, strapping 14 year old. He is looking forward to playing football on the freshmen team this fall. He needs his physical form completed before he can practice with the team. Aside from a handful of visits for minor illnesses, he hasn't had a physical since his kindergarten exam at 5 years of age. His mom sheepishly confesses, "I'd never get him to the office unless he was really sick."
Admittedly, most healthy children and teenagers seem indestructible...or so they'd like to think. "After all, what's the big deal with a physical when they're so healthy?" Kimberly's mom pleads in a polite, but almost defensive voice.
When reminded that they religiously service their car every 5,000 miles, or faithfully go to the dentist every 6 months, the usual response is, "But that's different!" Let's look at the yearly physical to see just how important it really is.
The history portion of the visit gives invaluable insight into how a person is doing overall. After exchanging the usual pleasantries of "how have you been this past year?" the doctor can assess the well-being of the patient by asking directed questions by system. All too often, teenagers have learned to accept their complaints as being "just something you have to live with." Or, they don't want to be "hassled with it." This is where the Review of Systems can be so important.
This is the part of the history whereby the questioning is broken down by organ system. Questions related to the head and neck can reveal a myriad of complaints that the parents were never even aware of. Are there headaches, problems with vision, eye strain or problems with hearing? This can identify problems of migraines, tension headaches, tempero-mandibular joint disease, the need for glasses, chronic fluid behind the ear drum, or just simple wax build-up. Is there a nighttime cough, increased post-nasal drip, pressure in the forehead or cheeks, or persistent bad breath? These could signal the presence of a chronic sinus infection, or allergies. Hardly the things that a busy teenager is likely to complain about.
Next comes the cardio-pulmonary system (heart and lungs). Is there coughing or wheezing with strenuous exercise? Does the patient fatigue easily while running, or does he experience a tightness in the chest? This could be the tip-off of an exercise-induced-asthma that could be easily remedied with inhaled broncho-dilators.
What about the teens eating habits? Is he, or she on any particular "diet?" Many teenagers, especially females, put themselves on a special diet that they "heard of," that actually falls short of meeting their nutritional requirements. Some of these can be dangerous. Some parents aren't even aware of these diets until they are discussed with the doctor. Are there problems with constipation, diarrhea, or bloody stools? I venture to guess that very few teens discuss their bowel habits with their parents unless there is something catastrophically wrong.
Next is the genito-urinary system (kidneys and bladder). Is there any frequency or difficulty when voiding? Does the patient have to get up during the night to urinate? For female patients it is important to discuss whether or not they have started their periods? If so, are they regular? Are there any problems with cramps during their period, or are they excessively heavy?
Most problems related to the musculo-skeletal system (bones and joints) are obvious, and medical care is usually sought for these. It is not uncommon however, for a teenager to "have a clicking in the knee," or "have a knee give out every now and then," and just learn to live with it or mention it to their parents in passing.
A detailed history would not be complete without a discussion of the skin. Acne is the bane of many teenagers, and most teens would rather die than discuss this with their parents. They usually treat the acne with over-the-counter preparations that are useless. When many parents ask the teens about the acne, they are met with an indignant, "It's my problem and I'll deal with it!" And the parents understandably back off.
Now comes the discussion about academic performance, activities in or outside of school, and plans for the future. Is the student performing up to his/her potential? Has there been a sudden decline in grades? If done tactfully, a careful history taker can broach the sensitive subject of alcohol and drug use, tobacco use, and sexual activity without being in any way threatening. This is a vital portion of the exam given the permissive society in which we live.
Before the exam, the nurse has recorded the pulse, blood pressure and height and weight. The vision has been checked, and the patient has given a urine specimen which has already been processed. These can categorically be reviewed with the patient with particular attention to high blood pressure, any abnormalities in the urine that would suggest a kidney problem, or the need for a formal eye exam. It is also important to plot the growth parameters of height and weight on a growth curve, comparing them with past values. Has the weight "taken off" over the past few years compared to the height? Is there a trend towards obesity? It might be the appropriate time for nutritional counseling.
The physical exam is self-explanatory. Let me just mention some of the "not so obvious" findings that can be detected during the exam. These include an enlarged thyroid gland, a thyroid cyst, unexplainable lymph nodes, a hernia, or a testicular mass. Listening to the heart may reveal an irregular beat, a "click," or a murmur. These may be symptom free, but can be dangerous and may warrant further evaluation. The spine exam can reveal scoliosis, an abnormal curvature of the spine, which may need an orthopedic referral.
Finally, the immunization status should be reviewed. The tetanus booster is usually due at around 15 years of age. If the patient is playing in a contact sport, this is important. Teenagers should have received their Hepatitis B vaccine (a series of 3 shots), and a second measles-mumps-rubella vaccine. If they have not had chickenpox, they should be immunized with the Varivax vaccine. It is wise to also give a TB skin test if they have not had one in the past few years.
Surprisingly, all this can be accomplished in 15-30 minutes. Is this excessive, or too much to ask, I think not...but you be the judge. It is not often that something abnormal does show up, but when it does, and it is detected early, it can be a rewarding experience. As the old adage goes, "An ounce of prevention..."