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A 14-year-old girl is brought to the office by her mother for a "camp check-up." She will be going to sleep away camp in a month, and needs you to fill out a form about her medical and immunization history. She has been a patient of yours since she was 4 years old, but has not been in for an examination in 18 months. The mother tells you that she is a "wonderful child" who gets A's in school, participates in after school sports, and gets along well with her siblings. She is not allowed to date boys until she is 16 years old. The patient is very quiet while her mother talks, and fails to make eye contact with you. The most appropriate next step is to
A. ask the girl if she wants her mother to leave the room
B. ask the girl to leave the room while you talk to the mother
C. ask the mother to leave the room while you evaluate the girl
D. do a complete physical and pelvic examination
E. recommend that the mother and daughter go to a psychiatrist together
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The correct answer is C. Adolescence is a time when girls are growing up and may not be sharing everything with their parents. It is always important to respect the patient and give her the opportunity to talk and be examined without her mother being present, especially in this case where the mother seems overbearing. The patient may be more forthcoming when interviewed and examined alone, and may verbalize complaints and concerns more easily. If she feels more comfortable with her mother there she can always tell you. You should make it clear that this is routine practice (to examine adolescents alone). If you are a male, you can ask her after her mother is gone if she is more comfortable with a female nurse present during the examination.
Asking the girl if she wants her mother to leave the room (choice A) is not the best choice because it may put her in an awkward position with her overbearing mother. If she says yes, the mother will say, "what are you going to tell him that you are not telling me?" and if she says no, you will not know if the girl is attempting to avoid upsetting her mother.
In this case, there is no reason to ask the girl to leave the room while you talk to the mother (choice B). The daughter is the one here for the examination and there is no apparent reason to talk to the mother alone. If this were a case of enuresis in a young child, it is usually important to talk to the parents alone to determine if there are any specific environmental stressors causing the condition.
It is usually best to talk to and examine an adolescent girl without her mother in the room. Therefore, the first step is not to do a complete physical and pelvic examination (choice D). Also, a pelvic examination is usually only indicated if she has specific pelvic complaints, or if she is sexually active.
There does not seem to be any reason to recommend that the mother and daughter go to a psychiatrist together (choice E). The mother seems a bit overbearing, but besides that, it is unnecessary for them to see a psychiatrist.
