A 16-year-old boy is brought to the office for a well-child visit. The patient has no medical history but reports that his appetite is low and he has lost 2.3 kg (5 lb). He stopped playing soccer recently due to lack of interest. The patient is also worried about his grades due to difficulty staying focused in class and concentrating on his homework after school. He feels tired despite sleeping 10 hours a night and taking afternoon naps when he gets home. The patient says, "My parents try to be supportive, but everything they say these days gets on my nerves." He has tried alcohol and marijuana a few times at parties but does not use other drugs. Vital signs are within normal limits. Physical examination is unremarkable. Which of the following is the most appropriate next step in management of this patient?

Question

A 16-year-old boy is brought to the office for a well-child visit.  The patient has no medical history but reports that his appetite is low and he has lost 2.3 kg (5 lb).  He stopped playing soccer recently due to lack of interest.  The patient is also worried about his grades due to difficulty staying focused in class and concentrating on his homework after school.  He feels tired despite sleeping 10 hours a night and taking afternoon naps when he gets home.  The patient says, "My parents try to be supportive, but everything they say these days gets on my nerves."  He has tried alcohol and marijuana a few times at parties but does not use other drugs.  Vital signs are within normal limits.  Physical examination is unremarkable.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec160b_364d_2753_9249_a37ab3b1f213_MD0001_00 This patient's loss of interest, weight loss, hypersomnia, low energy level, and impaired concentration are concerning for major depressive disorder (MDD). Depressed adolescents may experience feelings of annoyance and irritability rather than sadness. Other common signs are loss of interest in previously enjoyed activities, changes in academic functioning and relationships with peers and family, feelings of worthlessness/inappropriate guilt, and suicidal thoughts. Suicide is the third leading cause of death in adolescents age 15-19 years. Any adolescent with behavioral changes should be assessed for suicidal ideation, which has an immediate impact on safety and acute management (eg, an actively suicidal patient may require hospitalization). Therefore, the most appropriate next step is to assess this patient for suicidal thoughts. (Choice A) This patient's recent difficulty concentrating is one of multiple symptoms characteristic of depression. In attention deficit hyperactivity disorder, concentration difficulties are chronic, with typical onset prior to adolescence. (Choice B) It would be inappropriate to involve the parents prior to fully assessing the patient and his safety. (Choices C and D) A complete blood count and thyroid function testing may be included as part of a workup to rule out medical causes of depressive symptoms (eg, anemia, hypothyroidism or hyperthyroidism). However, these conditions are unlikely to be contributory in a patient with no medical history and a normal physical examination. In addition, the results of these tests take time, whereas suicidality and safety are immediate concerns. (Choice F) This patient appears to be forthcoming about his substance use and has no signs of intoxication or abuse. Screening the urine for drugs is unlikely to yield helpful information and may damage the trusting relationship with the patient. Educational objective: Depressed adolescents may display irritable rather than depressed mood, declining academic performance, and withdrawal from social activities. Initial evaluation of all children and adolescents with suspected depression should include a careful suicide risk assessment.

A 16-Year-Old Boy Is Brought to the Office for a Well-Child