A 13-year-old boy is brought to the physician by his mother for a routine physical examination and follow-up of type 1 diabetes mellitus. The patient appears irritated, and his mother begins the visit by exclaiming, "Here's the doctor; he's going to tell you how badly you've been doing." Laboratory tests show a random blood glucose of 350 mg/dL and a hemoglobin A1c of 9% (normal:

Question

A 13-year-old boy is brought to the physician by his mother for a routine physical examination and follow-up of type 1 diabetes mellitus.  The patient appears irritated, and his mother begins the visit by exclaiming, "Here's the doctor; he's going to tell you how badly you've been doing."  Laboratory tests show a random blood glucose of 350 mg/dL and a hemoglobin A1c of 9% (normal: <6%-7%).  When the physician asks the patient how he is doing with his insulin, the mother interrupts and shouts, "He never remembers to use it!"  When the boy is asked about his diet, the mother puts her hands on her hips, glares at her son, and says, "Pizza, soda, and candy!"  After acknowledging the mother's concerns regarding diabetic control, which of the following is the most appropriate course of action?

Quizplus · Accepted Answer

This patient's type 1 diabetes mellitus is poorly managed on his current treatment regimen, as indicated by a random blood glucose >200 mg/dL and hemoglobin A1c of 9.0%. The physician is confronted by an angry, critical parent who does not allow the patient to speak. Continuing the visit in the presence of the patient's mother will likely lead to unproductive conflict or the patient pacifying his mother by agreeing with her or allowing her to continue to speak for him (Choice B). The best course of action is to acknowledge the mother's concerns and politely ask her to wait outside while the physician speaks with the patient privately. This will allow the patient to be more open about his difficulty managing his diabetes and to discuss any personal concerns that may be having an impact. All adolescent visits should include an opportunity to interview the patient alone to discuss topics such as drugs, alcohol, tobacco, and sexual activity. (Choices A and C) Although this patient appears irritable and assessing his mood further is important, this should be done with the patient alone, where he can openly describe how he is feeling without his mother present. Although asking the mother if she has concerns about her son's mood may provide additional information, it is unlikely to give an accurate picture of his mood given the mother's angry frustration with his behavior. (Choice D) This statement is likely to be perceived as judgmental and to antagonize the mother, especially if it is delivered in front of the patient. A more productive approach is to speak with the patient privately and model appropriate behavior in joint discussions with the patient and mother. Educational objective: In situations in which a parent's presence may interfere with obtaining honest answers from an adolescent patient, physicians should politely ask the parent to wait outside and interview the patient privately. All adolescent visits should include an opportunity to interview the patient alone to discuss topics such as drugs, alcohol, tobacco, and sexual activity. __________ References: Talking to adolescents about alcohol, drugs and sexuality. (http://www.ncbi.nlm.nih.gov/pubmed/24608584) Parental involvement and adolescents' diabetes management: the mediating role of self-efficacy and externalizing and internalizing behaviors. (http://www.ncbi.nlm.nih.gov/pubmed/20926405)

A 13-Year-Old Boy Is Brought to the Physician by His