What are the components of a well-child exam visit for an 11-year-old female, including medical history, physical examination, and screenings?

Well-Child Visit for an 11-Year-Old Female

A comprehensive well-child visit for an 11-year-old female must include confidential time alone with the patient to screen for psychosocial risks, sexual health concerns, and mental health issues, as adolescents are significantly more likely to disclose sensitive information when given privacy. 1

Structure of the Visit

Initial Assessment with Parent/Guardian Present

Medical History Review:

• Growth and Development: Plot height, weight, and BMI on growth charts; assess pubertal development (Tanner staging) 1, 2
• Past Medical History: Review chronic conditions, hospitalizations, surgeries, medications, and allergies 1
• Immunization Status: Verify and update vaccines including HPV, Tdap, meningococcal, and annual influenza 1
• Family History: Screen for diabetes, cardiovascular disease, mental illness, substance abuse, and hereditary conditions 1
• Social History: Identify who lives in the home, school performance, learning difficulties, social interactions, and screen for intimate partner violence or substance abuse in the household 1

Confidential Time with Patient Alone

This is the most critical component for adolescents. Explain confidentiality limits clearly (harm to self/others, abuse) before beginning. 1

Psychosocial Screening (HEADSS Assessment):

• Home environment: Safety, relationships, conflicts 1
• Education/Employment: School performance, attendance, future goals 1
• Activities: Peer relationships, extracurricular activities, screen time 1
• Drugs/Substances: Tobacco, alcohol, marijuana, other substances 1
• Sexuality: Sexual activity, orientation, contraception needs, STI concerns, dating violence (9-60% of adolescents experience some form) 1
• Suicide/Depression: Screen for depression, anxiety, self-harm, suicidal ideation 1

Additional Confidential Screening:

• Eating behaviors and body image concerns: Screen for disordered eating 1
• Physical activity and sleep patterns 1
• Safety concerns: Seatbelt use, helmet use, weapon access 1

Physical Examination

Vital Signs and General Assessment:

• Blood pressure measurement 1
• Height, weight, BMI calculation and plotting 1
• General appearance, nutritional status 1

Complete Physical Examination:

• Skin: Examine for acanthosis nigricans (insulin resistance marker), bruising patterns (unusual locations like ears, neck, trunk suggest abuse), acne 1
• HEENT: Thyroid palpation, dental assessment (last dental visit), vision screening 1
• Cardiovascular and Respiratory: Complete examination 1
• Abdomen: Palpation for organomegaly 1
• Musculoskeletal: Scoliosis screening, joint examination 1
• Neurological: Age-appropriate assessment 1
• Tanner Staging: Assess breast development, pubic hair development privately 1, 2
• External Genital Examination: The American Academy of Pediatrics recommends assessing the hymen for patency and configuration during routine well-child visits, specifically looking for imperforate, microperforate, or cribriform hymen 3

Screening Tests and Laboratory Work

Vision Screening:

• Perform visual acuity testing using age-appropriate charts (HOTV, tumbling E, or standard Snellen) 1

Laboratory Screening (if not done recently):

• Lipid panel: Total cholesterol, LDL, HDL, triglycerides 1
• Hemoglobin/Hematocrit: Screen for anemia 1
• Consider additional screening based on risk factors: Diabetes screening if overweight/obese with risk factors, STI screening if sexually active, urine pregnancy test if indicated 1

Anticipatory Guidance

Safety:

• Seatbelt use, avoid distracted driving, helmet use for sports/bikes 1
• Water safety, firearm safety if guns in home 1

Nutrition:

• Limit sugar-sweetened beverages and juice 4
• Encourage balanced diet with fruits, vegetables, whole grains 4
• Discuss healthy weight management if needed 1

Physical Activity:

• Recommend 60 minutes daily of moderate-to-vigorous activity 1

Screen Time:

• Discuss limiting recreational screen time, avoiding screens before bedtime 4

Puberty Education:

• Discuss menstrual cycle if not yet started, menstrual hygiene 3
• If patient reports cyclical abdominal pain with no menstruation, urgent gynecologic referral is required to evaluate for imperforate hymen 3

Mental Health:

• Normalize emotional changes during puberty 1
• Provide resources for stress management 1

Sexual Health (if appropriate):

• Discuss healthy relationships, consent, contraception options if sexually active 1
• Offer HPV vaccination if not completed 1

Common Pitfalls to Avoid

• Failing to provide confidential time alone: Adolescents will not disclose sensitive information with parents present; 1 in 3 adolescent girls report missing needed care due to embarrassment 1
• Inadequate psychosocial screening: Station-based sports physicals are not comprehensive and miss behavioral risks 1
• Not explaining confidentiality limits: Clearly state what must be disclosed (abuse, harm to self/others) before screening 1
• Overlooking dating violence: This affects 9-60% of adolescents and is frequently missed 1
• Missing imperforate hymen: Failure to examine external genitalia can delay diagnosis until complications develop 3