What health maintenance, immunizations, screening, and counseling should be provided for a new 14-year-old female primary care patient?

Comprehensive Health Maintenance for a 14-Year-Old Female New Patient

For a 14-year-old female new patient, provide a comprehensive well-child visit that includes mandatory confidential time alone with the patient, complete psychosocial screening (depression, substance use, sexual health, violence), physical examination with blood pressure measurement, immunization review and administration (Tdap, HPV, meningococcal, influenza), and anticipatory guidance on safety, nutrition, and physical activity. 1, 2, 3

Structure of the Visit

Initial Assessment with Parent/Guardian Present

• Review complete medical history, including chronic conditions, medications, and allergies 2
• Document growth parameters (height, weight, BMI) and assess pubertal development using Tanner staging 1, 2
• Assess current health status, school performance, and sleep patterns 2
• Review immunization status and document dietary habits, physical activity level, and screen time 2

Mandatory Confidential Time Alone

• Explain confidentiality limits upfront: information will be kept private except when there is risk of harm to self or others, or evidence of abuse 3
• Approximately 58% of high school students report health concerns they wish to keep private from parents, making this confidential portion essential 1
• Almost 1 in 4 adolescent females report being too embarrassed to discuss important health issues when parents are present 1

Comprehensive Psychosocial Screening

Mental Health Assessment

• Screen annually for depression, anxiety, suicidal ideation, and self-harm behaviors using validated tools, as suicide is among the leading causes of death for adolescents 2, 3
• Approximately 80% of adolescents who need mental health treatment are not receiving care 1, 3
• Assess social adjustment, peer relationships, and school performance 2

Substance Use Screening

• Use the CRAFFT screening questionnaire to assess for alcohol, marijuana, tobacco/nicotine (including e-cigarettes and vaping), and other drug use 3
• Substance abuse is a leading cause of adolescent morbidity and mortality 2, 3

Sexual and Reproductive Health

• Screen for sexual activity, number of partners, contraception use, and history of sexually transmitted infections 1, 2
• Discuss consent, healthy relationships, and STI/pregnancy prevention 1, 2
• Provide education on the full range of contraceptive methods, including barrier methods, hormonal contraception, long-acting reversible contraception, and emergency contraception 4
• Starting at puberty, incorporate preconception counseling into routine visits, including discussion of folic acid supplementation for all females of reproductive age 4

Violence and Safety Screening

• Screen for involvement in or victimization from physical, sexual, or emotional violence, dating violence, or abuse 4, 3
• Assess for bullying and evaluate peer relationships 3

Physical Examination

Vital Signs and General Examination

• Measure blood pressure annually using proper technique with age-appropriate cuff size; if elevated (≥90th percentile), recommend lifestyle interventions and recheck in 6 months by auscultation 1, 2, 3
• Perform complete physical examination including vital signs, skin examination (assess for signs of self-harm or abuse), and genitourinary examination 2, 3
• Assess for signs of physical abuse or neglect 2

Laboratory Screening

Recommended Screening Tests

• Lipid panel screening if family history of hyperlipidemia or cardiovascular disease, or if not previously screened between ages 9-11 years 1, 3
• Hemoglobin/hematocrit screening 1
• For sexually active adolescents: screen for gonorrhea, chlamydia, and HIV 4, 3

Immunizations

Required Vaccines at Age 14

• Tdap booster (if not previously given at age 11-12) 1, 3
• HPV vaccine series: give a strong recommendation emphasizing cancer prevention, normalize by coadministering with other vaccines 1, 3
• Meningococcal conjugate vaccine 1, 3
• Annual influenza vaccine 1, 3
• Review and catch up any missed childhood vaccinations 1, 3

Anticipatory Guidance and Health Promotion

Injury Prevention

• Emphasize seatbelt use, helmet use for sports/cycling, avoidance of distracted and impaired driving, as unintentional injuries are the leading cause of adolescent death 1, 2, 3
• Discuss firearm safety, including safe storage and access 1

Nutrition and Physical Activity

• Discuss healthy eating patterns, limiting sugar-sweetened beverages, and appropriate portion sizes 1, 2, 3
• Recommend at least 60 minutes of moderate to vigorous physical activity daily, including resistance and flexibility training 2, 3
• Screen for eating disorders and body image concerns 1

Sleep and Screen Time

• Assess sleep patterns and recommend 8-10 hours of sleep nightly 3
• Recommend limiting screen time before bedtime 3
• Screen for obstructive sleep apnea if indicated 2

Substance Use Prevention

• Discourage tobacco/nicotine use, electronic cigarettes, and vaping 4
• Discuss risks of alcohol use and strategies to minimize harm 4
• Advise against recreational cannabis use in any form 4

Critical Pitfalls to Avoid

• Never conduct brief "sports physicals" instead of comprehensive examinations—these lack psychosocial screening and confidentiality, missing opportunities for early diagnosis and treatment of conditions causing significant morbidity and mortality 1, 2, 3
• Never skip confidential time alone with the adolescent—this results in missed screening opportunities for risky behaviors that directly impact mortality and morbidity 1, 2, 3
• Never skip depression screening—it must be performed annually starting at age 11, as suicide is a leading cause of adolescent death 1, 3
• Never defer HPV vaccination—provide a strong recommendation and normalize it by coadministering with other vaccines 1, 3
• Never focus only on physical health while neglecting behavioral and developmental aspects 2
• Never rely solely on parental report without engaging the adolescent directly 2