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Despite reluctance, teens need physical exam.


BELLEVUE, WASH. -- Talking with your teenage patients is important, but don't forget to examine their bodies.

"We spend so much time talking to them, we don't put on our medical provider hats and actually verify that things are okay and that they're on the right growth trajectory," Dr. Cora C. Breuner said at the conference. When that happens, "we miss things."

Lots of girls have asymmetrical breasts and are very concerned about it, but don't know how to ask a physician about it. Lots of boys have gynecomastia, are very embarrassed by it, and don't know how to talk about it. For the 10%-30% of boys who are uncircumcised (depending on the population), chances are no one is talking to them about how to dean the penis.

"You can normalize so much during their physical exam when you do the exam yourself," said Dr. Breuner, professor of pediatrics and adolescent medicine at the University of Washington, Seattle.

Some physicians skip the exam or have another provider do it because they feel pressured for time. Others don't want to make the patient uncomfortable by examining everything including genitals, or the patient refuses to undress. Have a chaperone present during physical exams if you need to, "but do your exams," she stressed. "You can catch things that no one else will note."

Especially for sports physical exams, there's no way to know if boys have matured physically enough to play contact sports without examining development of the genitals and pubic hair. With girls, if they have reached menarche, they're probably a Tanner stage W in terms of their epiphysis (growth plates) being closed, making them eligible for contact sports. Either sex may balk at the idea of a physical exam. "Too bad. It's our job," Dr. Breuner said.

She tells boys she needs to do a complete exam and will just look at the penis and testicles to make sure everything is okay. The usual response is a grumbly, "I'm not doing that. No way." So she'll say to them, "You know what? I can actually tell if you're going to be any taller by just doing an exam. I can tell whether you are finished with your height, or whether you still have 4 to 6 more inches to grow." She's always amazed at how that eases the process.

The exam takes a few seconds, and as she's washing her hands and the boy is putting his pants back on, she may tell him he is not at all done with his height trajectory. "They're so reassured, because they haven't been able to talk to anyone about this, and they're so afraid someone's going to say that something is wrong," Dr. Breuner said.

Peak adolescent growth spurts tend to happen 2 years later in boys (typically at ages 14-16 for boys and 12-14 for girls), feeding their anxiety about this. Growth still may be possible for boys in their last year of high school or first year of college, but generally is finished in girls by the time they're 16.

The timing of genital changes also tends to occur 2 years later in boys than in girls. Some girls may develop breasts as early as 8 years of age and others not until they're 13, but both are normal. Menarche normally occurs between ages 10 and 16 1/2, she said.

Despite guidelines recommending annual physical exams for adolescents, physicians often only see them for annual sports physicals or vaccinations. "Spend some time on the social aspect as well as the physical," she said. The top three causes of death in adolescents are motor vehicle accidents, suicides, and homicides. At least, give them a three-point message, she suggested: "Don't drink and drive. Don't text and drive. Here's your vaccine."

Dr. Breuner had no disclosures.
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Title Annotation:CLINICAL ROUNDS
Author:Boschert, Sherry
Publication:Pediatric News
Date:Jun 1, 2012
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