Exam 2 Flashcards
What are the normal heart sounds and their characteristics?
S1 ‘lubb’ marks the beginning of systole, caused by closure of mitral and tricuspid valves. S2 ‘dubb’ marks the beginning of diastole, caused by closure of aortic and pulmonary valves.
S1 is louder at the apex; S2 is louder at the base, higher pitched & shorter.
What is S2 physiologic splitting?
S2 consists of aortic (A2) and pulmonic (P2) valve closure. On inspiration, A2 is heard first, followed by P2. On expiration, the two sounds are close together and detected as a single S2.
Usually heard in younger patients.
What are abnormal heart sounds?
Abnormal heart sounds include S3, S4, systolic clicks, pathologic splitting, rubs, or gallops.
Pathologic splitting can be wide, fixed, or paradoxical.
What is S3 and its significance?
S3 is a physiologic sound frequently heard in children and young adults, occurring early in diastole, dull and low in pitch. Pathologic S3 indicates high left ventricular filling pressures.
Causes include decreased myocardial contractility and heart failure.
What is S4 and its common causes?
S4 is an ‘atrial sound’ that occurs just before S2, dull and low in pitch, commonly due to ventricular hypertrophy or fibrosis.
Causes include HTN heart disease and aortic stenosis.
What are normal peripheral vascular findings?
Normal findings include strong and equal pulses (2+) in major arteries, brisk capillary refill (< 3 seconds), lack of edema, normal hair distribution, and an ankle-brachial index (ABI) between 0.9 – 1.4.
Equal limb circumference and symmetrical warmth are also indicators.
What are abnormal peripheral vascular findings?
Abnormal findings include weak/absent pulses, bounding pulses, delayed capillary refill, pitting edema, calf asymmetry, unilateral swelling, and bilateral edema.
Visible venous collaterals may indicate upper extremity DVT.
Define heart failure.
Heart failure is the heart’s inability to pump enough blood to meet the body’s needs, also known as congestive heart failure.
Hallmark features include edema, shortness of breath, and testing with ECG, chest X-ray, and echocardiogram.
What is angina pectoris?
Angina pectoris is chest pain or discomfort due to decreased oxygen to the heart muscle, characterized by substernal pressure that can radiate to the shoulder, arm, neck, or jaw.
Testing includes ECG and stress tests.
What is mitral valve prolapse (MVP)?
MVP is a defect of the mitral valve causing improper closure and backflow of blood into the left atrium, characterized by a mid-systolic click and late systolic murmur.
Echocardiogram is the primary test.
What is Raynaud’s phenomenon?
Raynaud’s phenomenon is temporary narrowing of blood vessels in extremities causing color changes in response to stress or cold.
Symptoms include numbness and tingling.
What is deep vein thrombosis (DVT)?
DVT is blood clot formation in a deep vein, characterized by swelling, discoloration, pain, and warmth in the affected extremity.
Testing includes ultrasound and D-dimer labs.
What are the symptoms of arterial insufficiency?
Symptoms include intermittent claudication, cold or pale legs, weak pulses, and skin changes such as thin, shiny skin and ulcers.
Complications can lead to gangrene or amputation.
What characterizes venous insufficiency?
Venous insufficiency is a condition where veins cannot return blood effectively to the heart, leading to symptoms like swelling, heaviness, and aching in the legs.
It can cause brownish pigmentation and venous ulcers.
Differentiate between venous ulcers and arterial ulcers.
Venous ulcers: occur above the ankle, are shallow with irregular borders. Arterial ulcers: occur on toes or heels, are deep with well-defined borders.
Venous ulcers are due to poor venous return; arterial ulcers are due to poor arterial circulation.
Where are heart murmurs best heard?
Heart murmurs are best heard in the four valve areas: Aortic area, Pulmonary area, Tricuspid area, Mitral area.
Specific intercostal spaces correspond to each area.
What are physiologic murmurs?
Physiologic murmurs are innocent, functional murmurs common in children, usually normal sounds made as blood pumps through the heart.
They may get louder when a child is excited or ill.
What are pathologic murmurs?
Pathologic murmurs are associated with structural heart disease, often require medical intervention, and can indicate heart problems.
They are typically loud and may have a blowing or squeaky sound.
What are some methods of assessing heart murmurs?
Assessment methods include maneuvers like handgrip, squatting, Valsalva, and standing abruptly.
These maneuvers can change the intensity of different murmurs.
What is the grading system for heart murmurs?
Murmurs are graded from I to VI. Systolic murmurs occur between S1 and S2, while diastolic murmurs occur between S2 and S1.
Systolic murmurs always end in VI; diastolic always in IV.
What are the screening recommendations for alcohol abuse?
Screen all adults for unhealthy alcohol use, assess family history, social problems, and use the CAGE questionnaire.
Look for signs of liver disease during physical examination.
What questionnaire is used to screen for alcohol misuse?
CAGE questionnaire
The CAGE questionnaire is a widely used tool for identifying potential alcohol problems.
What are signs of liver disease to assess during a physical examination?
Signs include:
* Hepatosplenomegaly
* Ascites
* Caput medusae
* Jaundice
* Spider angiomas
* Palmar erythema
* Dupuytren contractures
* Gynecomastia
These signs may indicate underlying liver dysfunction or disease.
What is the recommended alcohol consumption limit for women?
Up to one drink/day
This recommendation is based on guidelines from the U.S. Office of Disease Prevention and Health Promotion.
What is the recommended alcohol consumption limit for men?
Up to two drinks/day
This recommendation is based on guidelines from the U.S. Office of Disease Prevention and Health Promotion.
Which hepatitis viruses are vaccine-preventable?
Hepatitis A and Hepatitis B
Vaccination can significantly reduce the risk of these infections.
How is Hepatitis A virus (HAV) transmitted?
HAV is transmitted through:
* Contact with contaminated objects
* Food
* Drinks contaminated by feces from an infected person
* Injection drug use
* Sexual/household contact with a hepatitis A patient
Understanding transmission routes is essential for prevention.
Who should be vaccinated against Hepatitis A?
Vaccination is recommended for:
* All children at age 1 year
* Individuals with chronic liver disease
* High-risk groups (e.g., travelers to endemic areas, men who have sex with men, injection drug users)
This helps prevent outbreaks and protect vulnerable populations.
What is the fatality rate of acute hepatitis B virus (HBV) infection?
1%
This statistic highlights the severity of acute HBV infection.
What percentage of adults become chronically infected with HBV?
Around 5%
Infants and young children are at a much higher risk for chronic infection.
What populations are recommended for HBV screening?
Screening is recommended for:
* People born in high-prevalence countries
* Unvaccinated individuals with parents from high-prevalence regions
* Men who have sex with men
* Injection drug users
* People with HIV
* Household contacts of HBV-infected individuals
* People requiring immunosuppressive therapy
Early detection can prevent complications from HBV.
What is the CDC recommendation for hepatitis B vaccination?
Vaccination is recommended for:
* All infants
* Unvaccinated children <19 years
* At-risk individuals for sexual exposure and percutaneous exposure
Vaccination is crucial for preventing HBV infection.
How is Hepatitis C virus (HCV) mainly transmitted?
HCV is mainly transmitted by:
* Parenteral exposures to infectious blood or body fluids
Understanding transmission is key to prevention.
Which individuals are at increased risk for HCV infection?
Increased risk is associated with:
* Current/former injection drug users
* Recipients of clotting factor concentrates before 1987
* Recipients of blood transfusions/organ transplants before July 1992
* Chronic hemodialysis patients
* Known exposures to HCV
Regular testing is recommended for these populations.
What is the primary role of the APRN regarding hepatitis C?
Counsel patients to avoid risk factors and screen all adults and pregnant women
There is no vaccine for hepatitis C, making prevention and early detection crucial.
What is the second-leading cause of cancer death in the United States?
Colorectal cancer
Awareness of risk factors and screening is essential for prevention.
At what age does the USPSTF recommend colorectal cancer screening?
Aged 50 to 75 years
Screening can significantly reduce mortality from colorectal cancer.
What are the recommended screening tests for colorectal cancer?
Recommended tests include:
* High-sensitivity guaiac fecal occult blood test (HSgFOBT) - yearly
* Fecal immunochemical test (FIT) - yearly
* Colonoscopy - every ten years
* CT Colonography - every five years
Regular screenings help in early detection and management.
What are the key features of Hepatitis?
Key features include:
* Jaundice
* Elevated liver enzymes
* Fatigue
* Nausea
* Abdominal pain
* Dark urine
* Light-colored stools
* Ascites
These symptoms can help in diagnosing hepatitis.
What is the most common cause of pancreatitis?
Gallstones
Other causes include alcohol abuse and trauma.
What is a key feature of peptic ulcer disease (PUD)?
Epigastric pain, melena, food-dependent pain
H. Pylori infection is a common etiology.
What are the symptoms of cholecystitis?
Symptoms include:
* RUQ pain
* Murphy’s sign (+)
* Fever
* Nausea
* Bloating
* Jaundice
These symptoms can indicate inflammation of the gallbladder.
What is the primary etiology of diverticulitis?
Confined inflammatory process in the sigmoid colon
LLQ pain and fever are common symptoms.
What are common signs of cirrhosis?
Common signs include:
* Ascites
* Jaundice
* Hepatic encephalopathy
These signs indicate advanced liver disease.
What is a key feature of appendicitis?
RLQ pain (McBurney’s point) and rebound tenderness
Early recognition is crucial to prevent complications.
What is the common symptom of peritonitis?
Board-like abdomen and severe pain
This condition often requires immediate medical intervention.
What are the signs of abdominal distention?
Signs include:
* Asymmetry
* Bulging umbilicus
* Increased pulsations
* Ecchymosis
Distention can indicate several underlying conditions.
What is the significance of rebound tenderness during palpation?
Indicates peritoneal irritation
This is a critical finding in abdominal examinations.
What does a rigid abdomen suggest?
Peritoneal irritation
This finding can indicate acute conditions needing surgical intervention.
What are common symptoms associated with lesions and bloody diarrhea?
Frequent bowel movement, fatigue, loss of appetite, weight loss.
What is the genetic risk factor for Ulcerative Colitis (UC) in first-degree relatives?
Higher risk compared to the general population; less genetic influence than Crohn’s disease.
What role do HLA genes play in gut health?
Involvement in defective immune response to gut microbiota.
What is a hernia?
A bulging mass that causes pain with strain.
What can cause the formation of certain hernias?
Failure of normal closure, connective tissue disorders, and increased intra-abdominal pressure.
What are some connective tissue disorders that increase hernia risk?
- Ehlers-Danlos syndrome
- Marfan syndrome
- Osteogenesis imperfecta.
What are common symptoms to inquire about during a breast health history?
- Lumps
- Pain
- Nipple discharge.
What is the significance of a lump in the breast?
Identify precise location, duration, and any change in size or variation within the menstrual cycle.
What should be assessed regarding nipple discharge?
- Occurrence
- Color
- Quantity
- Frequency.
Define dysmenorrhea.
Pain before or during menses.
What are the three criteria for diagnosing PMS?
- Signs and symptoms in five days before menses for at least three consecutive cycles
- Symptoms end within four days after onset of menses
- Interferes with daily activities.
What is amenorrhea?
General absence of periods.
What is the difference between primary and secondary amenorrhea?
- Primary: periods never started
- Secondary: cessation of periods after they have been established.
What is menorrhagia?
Excessive menstrual flow.
What are vasomotor symptoms associated with menopause?
- Hot flashes
- Flushing
- Sweating.
What does Gravida Para notation signify?
Gravida (G) = total pregnancies; Para (P) = number of births.
What is the significance of the term ‘living child’ in Gravida Para notation?
It refers to the number of living children currently held by the mother.
What should be assessed regarding sexual health history?
- Contraception methods
- History of Pap smear screenings
- Vulvovaginal symptoms.
What are common causes of abnormal vaginal discharge?
- Bacterial vaginosis
- Trichomoniasis
- Candidal vaginitis.
What is important to consider when discussing sexual history with patients?
Use a neutral, non-judgmental tone and ensure patient comfort.
What does low libido or erectile dysfunction indicate?
Possible psychogenic causes, decreased testosterone, or vascular, neurologic, or endocrine problems.
What symptoms may indicate a sexually transmitted infection in males?
- Penile discharge
- Lesions
- Scrotal swelling.
What is the significance of blood in the stool?
May indicate GI bleeding, polyps, hemorrhoids, or carcinoma.
What are common urinary symptoms to inquire about for prostate health?
- Difficulty starting or maintaining stream
- Weak stream
- Blood in urine.
What are the main techniques for performing a breast exam?
- Inspection in various positions
- Palpation with fingers in concentric circles.
What is included in the pelvic exam for females?
- External inspection of vulva
- Speculum exam
- Bimanual exam.
How is a hernia examination best performed?
With the patient standing.
What is the duration of regular menstrual bleeding?
3-7 days
What is the frequency range for regular menstrual cycles?
Every 21-35 days
What are the characteristics of irregular periods?
Varying cycle lengths
What are potential causes of irregular periods?
- Stress
- Hormonal imbalances
- Thyroid issues
What is intermenstrual spotting?
Bleeding that occurs between menstrual periods
What are potential causes of intermenstrual spotting?
- Ovulation
- Hormonal contraceptives
- Fibroids
What is menorrhagia?
Heavy menstrual bleeding
What are characteristics of menorrhagia?
- Soaking through one or more pads or tampons every hour for several hours
- Clots larger than a quarter
What are possible causes of menorrhagia?
- Uterine fibroids
- Adenomyosis
- Hormonal imbalances
- Bleeding disorders
What is primary amenorrhea?
Absence of periods by age 16
What is secondary amenorrhea?
Cessation of periods for three consecutive cycles or more
What are possible causes of amenorrhea?
- Pregnancy
- Significant weight loss
- Excessive exercise
- Hormonal disorders (like PCOS)
What is implantation bleeding?
Light spotting around the time of expected period (6-12 days post-conception)
What are characteristics of miscarriage?
- Heavy bleeding
- Severe cramping
- Passage of tissue
What is a characteristic of ectopic pregnancy?
Sharp pelvic pain with light to heavy bleeding
What are characteristics of perimenopausal bleeding?
- Irregular periods
- Heavier or lighter flow
What are common signs of infections causing abnormal bleeding?
- Abnormal discharge
- Odor
- Itching
What types of cancer may cause unexplained bleeding?
- Uterine
- Cervical
- Ovarian cancer
What is the most commonly diagnosed cancer in the world?
Breast cancer
What are benign lumps in the breast typically caused by?
Conditions like fibroadenomas or cysts
What are characteristics of malignant lumps in the breast?
- Hard
- Irregular
- Immovable
What does peau d’orange refer to?
Skin that appears dimpled and resembles the surface of an orange
What can nipple discharge indicate?
Infection or cancer
What does localized pain in the breast suggest?
An underlying problem such as infection or a growing mass
What are symptoms of mastitis?
- Redness
- Warmth
- Swelling
- Pain
What does skin dimpling or puckering indicate?
Changes in the underlying tissue, such as tumors
What anatomical landmarks are important for identifying hernias in the groin?
- Anterior superior iliac spine
- Inguinal ligament
- Pubic tubercle
What are risk factors for acute epididymitis?
- Sexually transmitted infections
- Urinary tract infections
- Indwelling urethral catheters
What is the clinical presentation of testicular torsion?
- Sudden, severe unilateral scrotal pain
- Nausea and vomiting
- Swelling and erythema
What does a varicocele feel like?
A ‘bag of worms’ in the spermatic cord
What is hypospadias?
Congenital displacement of the urethral meatus to the inferior surface of the penis
What is the primary cause of acute bacterial prostatitis?
Gram-negative enteric organisms like E. coli
What are symptoms associated with benign prostatic hyperplasia (BPH)?
- Urethral obstruction symptoms (hesitancy, incomplete emptying)
- Irritative symptoms (urgency, frequency, nocturia)
What is a normal prostate size?
About the size of a walnut (2–3 cm)
What are concerning signs indicating the possibility of prostate cancer?
Distinct hard nodules with irregular border on the gland
These nodules should be further evaluated as the cancer may extend beyond the prostate gland.
What is the typical size and texture of a normal prostate?
About the size of a walnut (2–3 cm), feels rubbery
Normal findings include a smooth and nontender prostate with a palpable median sulcus.
What is central cyanosis and why is it significant in pediatrics?
Always abnormal; could indicate a cardiac or respiratory abnormality
It is assessed by examining the inside of the mouth, tongue, conjunctiva, and skin.
What are the symptoms that may indicate an underlying heart defect in infants?
Work of breathing and diaphoresis while feeding
Assessment should occur during feeding for infants and during activity for older children.
What are thrills and what do they indicate?
Palpable vibrations that may show cardiac abnormalities
Assess the quality of pulses in upper and lower extremities, especially femoral pulses.
What is the significance of diminished or absent femoral pulses?
Usually caused by coarctation of the aorta
This is a critical finding that requires further evaluation.
What is sinus dysrhythmia in infants?
A normal variant where heart rate increases on inspiration and decreases on expiration
It is common in infants and children.
What should be noted when auscultating for heart murmurs in infants?
Specific location, timing, intensity, and quality of the murmur
Some murmurs, like a closing ductus, can be benign.
What is witch’s milk in newborns?
White liquid secreted from enlarged breasts due to maternal estrogen
This can last for one to two weeks and is a normal variant.
What are common findings in the abdomen of infants?
Infection of the umbilical stump, umbilical granuloma, and umbilical hernias
Hernias should be reducible and less than five centimeters in diameter.
What is cutis marmorata?
A normal response in infants characterized by a lattice-like bluish modeling due to cooling
It can also occur from chronic exposure to radiant heat.
What does a café au lait spot indicate?
Normal variance unless there are more than five or include axillary freckling
This can be indicative of neurofibromatosis if present in excess.
What is the appearance of miliaria rubra?
Scattered vesicles on an erythematous base, often referred to as baby acne
This condition can be common in infants.
What is the significance of the anterior fontanelle measurement at birth?
Measures 4–6 centimeters and usually closes by 18 months of age
Its bulging can indicate increased ICP or hydrocephalus.
What is cephalohematoma?
Localized scalp swelling caused by birth trauma that does not cross suture lines
This is different from caput succedaneum which does cross suture lines.
What is a normal finding regarding the red reflex in infants?
A positive red reflex indicates healthy eyes
Absence can indicate congenital cataracts or retinoblastoma.
What does low set ears indicate?
Can indicate renal disease or Down syndrome
An imaginary line across the inner and outer canthi of the eye should cross the pinna.
What is choanal atresia?
A condition characterized by obstruction of the choanae
Only the maxillary and ethmoid sinuses are present at birth.
What is the expected number of primary teeth in infants?
One tooth for each month of age between six and 26 months, with a maximum of 20 primary teeth
This is a normal developmental milestone.
What is cryptorchidism?
A condition where one or both testes are undescended
It usually self-corrects by one year of age; surgery may be required if not.
What are the Ortolani and Barlow tests used for?
To assess for developmental dysplasia of the hip
Barlow tests for dislocation while Ortolani confirms it.
What are common skin conditions in infants?
Seborrheic dermatitis, atopic dermatitis, candidal diaper dermatitis, and contact dermatitis
Each has distinct characteristics and causes.
What is impetigo?
A bacterial skin infection causing honey-colored crusted lesions
It is common in summer and winter months.
What is the appearance of tinea capitis?
Scaling, crusting, and hair loss in the scalp
Often accompanied by an enlarged occipital lymph node.
What characterizes hives (urticaria)?
Very pruritic, erythematous rash that changes shapes
Can present in one area and then disappear to another.
What does allergic rhinitis look like in children?
Boggy, mucous membranes with symptoms like mouth breathing and ‘allergic shiner’
Children may also exhibit an ‘allergic salute.’
What is thrush?
White plaques in the mouth that do not rub off
Common in infants but can indicate problems in older children.
What are the red flags for developmental skills in infants?
Not making age-appropriate sounds/language or plateau/loss of developmental skills
These may indicate need for further assessment.
What is the expected motor development milestone for infants by 6 months?
Can sit with support
Infants learn head control before trunk control.
At what age should children be able to jump and ride a tricycle?
By four years of age
This is part of their gross motor development.
What are the normal language development milestones for infants by 1 year?
Saying one to three words
Development starts with cooing and progresses to babbling at 6 months.
What is a red flag in socio-emotional skills for toddlers?
Plateau or loss of developmental skills
Tantrums are common and a natural part of development.
What are common signs of abnormalities observed during play in infants and young children?
Inappropriate discipline, difficult temperament, poor parent-child interaction, gross or fine motor delay, language delay, socio-emotional delays
Observing play is key for examiners.
What major developmental task is emphasized for children attending school?
Self-efficacy or the ability to thrive in different situations.
What is a red flag indicating developmental concerns in children?
Plateau or loss of developmental skills.
What should examiners observe during play in infants and young children?
Signs of abnormalities such as inappropriate discipline, difficult temperament, and motor or language delays.
What is a common cardiac finding in infants related to heart rate?
Sinus dysrhythmia, where HR increases on inspiration and decreases on expiration.
What is Paroxysmal Supraventricular Tachycardia (PVST)?
The most common dysrhythmia in children, characterized by a heart rate of 220 bpm or greater.
What type of murmur is benign in infants and can be heard during the first few days of life?
Closing ductus murmur.
What is a Still’s murmur, and when is it typically observed?
Grade I–II/VI, musical, vibratory murmur seen in preschool or early school age.
True or False: Central cyanosis is always abnormal.
True.
What are potential symptoms of congenital heart defects in infants during feeding?
WOB (work of breathing) and diaphoresis.
What does a ‘rolling’ heave at the left sternal border suggest?
An increase in right ventricular work.
What condition is associated with absent or diminished femoral pulses?
Coarctation of the aorta.
What does persistent splitting of S2 potentially indicate?
Atrial septal defect.
What is the significance of a true gallop rhythm in heart failure?
It indicates tachycardia plus a loud S3 and S4.
What are the characteristics of Tetralogy of Fallot?
VSD, infundibular and valvular right ventricular outflow obstruction, malrotation of the aorta, and right to left shunting.
Fill in the blank: Persistent nystagmus, shaking eye movement, is a concern and should be further investigated as it could indicate some _______.
neurological disorder.
What should be assessed when examining muscle tone in infants?
Muscle tone should be assessed while doing a passive range of motion.
What are primitive reflexes, and why are they important?
Primitive reflexes are reflexes present in infants and their absence or abnormal presence can indicate neurological issues.
What is the first step in a general pediatric examination?
Establish rapport with both the child and caregiver.
What history should be gathered for infants during a pediatric examination?
Birth history, feeding and diet history, growth parameters, developmental milestones, immunization status, parental concerns.
What is the significance of observing general appearance and symmetry in infants?
It helps assess interaction with caregivers and overall responsiveness.
What are key components of the physical examination for toddlers?
Developmental milestones, diet and nutrition, sleep habits, behavioral concerns.
What should be included in the physical examination of preschoolers?
General observation, vitals, vision and hearing screenings, oral health, chest and heart assessment.
What age group should have blood pressure measured starting at age 3?
School-aged children (6 to 12 years).
What is a common assessment for social behaviors in preschoolers?
Peer relationships and behavior at home and preschool.
What are the components of a cardiovascular examination in children?
Cardiac murmurs, PMI location
PMI stands for point of maximal impulse, an important assessment in cardiac examinations.
What should be assessed in the abdomen during a physical examination?
Tenderness, bowel sounds, hernia check
What are the key aspects to evaluate in the genitourinary examination?
Anatomical normalcy, cleanliness, injury signs
What musculoskeletal aspects are evaluated in children?
Balance, coordination, gait, scoliosis screening (if indicated)
What neurological aspects are assessed in children?
Motor coordination, fine motor skill assessment
What are the key history components for school-aged children (6 to 12 years)?
Academic performance, social activities, physical activity levels, screenings
What should be included in the physical examination of school-aged children?
General observation, vitals, vision/hearing, dental, chest/cardiovascular, abdomen, genitourinary, musculoskeletal, neurological
What are the vital signs to monitor in school-aged children?
Growth patterns (height, weight, BMI percentiles), BP screening routine
What is assessed in the genitourinary examination for school-aged children?
Tanner staging initiation, hygiene, development
What psychosocial aspects are covered in the HEADSS assessment for adolescents?
Home environment, education/employment, activities, drugs/substance use, sexual activity, suicide/depression
What general aspects should be observed during the physical examination of adolescents?
Hygiene, appearance, emotional state
What are the key components of the breast exam in adolescents?
Tanner staging, asymmetry, lumps
What is included in the genitourinary examination for adolescent females?
Tanner staging, menstrual irregularities
What is included in the genitourinary examination for adolescent males?
Testicular exam, education on self-exam
What musculoskeletal aspects are assessed in adolescents?
Postural deviations (kyphosis, scoliosis), sports injury assessment
What key reminders should be followed across all age groups?
Adapt assessment style, include anticipatory guidance, approach with sensitivity
Fill in the blank: In assessing adolescents, it is important to offer private discussion to reassure _______.
privacy/confidentiality
