Academic journal article International Journal of Child Health and Human Development

Psychocutaneous Diseases in Adolescents

Academic journal article International Journal of Child Health and Human Development

Psychocutaneous Diseases in Adolescents

Article excerpt

Introduction

A complete history and physical examination is important to be performed by the competent clinician when evaluating the pediatric patient with clinical concerns including psychocutaneous disorders. A focused history can be utilized as time permits but sometimes a more comprehensive evaluation is needed to find the correct diagnosis after a succinct differential diagnosis which leads to selective laboratory testing and the optimal management based on establishing the correct diagnosis.

History taking skills in adolescent patients

The interview process is a key component in evaluation of pediatric patients, particularly the adolescent who presents with dermatological disorders (1). The medical interview is typically separated into three core components: information gathering, relationship building, and patient education. The six basic aspects of successful clinician-patient communication is identified in Table 1 in which the opening discussion is the initial step followed by the ability to collect key information in addition to sharing information that the pediatric patient needs to understand for optimal management compliance (2-4).

Understanding the patient's perspectives is an integral part of this overall process in order to reach a mutual agreement between clinician and patient in regards to identified dermatological problems as well as psychological issues and recommended management plans. This is especially important when dealing with older children and adolescents. The final step in this interaction is properly closing the medical interview to allow the patient (and family for children) to successfully leave the encounter feeling that their questions were answered and that they are willing to return after following the clinician's recommendations.

Table 2 lists various clinician-patient communication patterns (4). The least favorite pattern is the "narrow biomedical interview" model since it is very closely clinician-controlled as seen in this miniscenario:

Clinician: What brings you (the patient) in today?

Patient: I have pimples.

Physician: Where are the pimples? When did it start? How long has it been bothering you? Are you taking any medications for it?

In this example, the patient is quickly interrupted with a barrage of queries and the clinician fails to use the "continuer" technique to identify all the issues the patient (and/or family) may have. Also, it fails to appreciate nonverbal patient cues, such as: "You seem upset today-can you tell me about that?"

There is some dialogue on psychosocial and behavioral issues in the "expanded biomedical model"; however, it remains dominated by the interviewer. A much healthier model is the "biopsychosocial" one in which there is a better balance of control between the adolescent and clinician. Patients control the "psychosocial model" and this is more popular with adult patients. Finally, the model that is often not popular with clinicians is the "consumerist model" since it is fully controlled by the patient who seeks answers to miscellaneous questions.

The American Academy on Physician and Patient (AAPP) has developed the PEARLS mnemonic to review core elements of the medical interview (Table 3) (2-4). The concept of the link between patient and physician is noted by the term Partnership that is between the patient and clinician. Empathy means that the clinician expresses an understanding of the patient (and family) for the newborn, child, or adolescent patient. Apology notes that the clinician should apologize for lateness in seeing the patient or lateness in getting laboratory tests. Clinicians should acknowledge the patient's suffering and difficulties as suggested in the term Respect while Legitimization means that the clinician acknowledges feelings of the patient or family (i.e., being upset, sad, anxious, others). Finally, Support suggests the critical idea that clinicians provide the patient (and family in younger patients) with the concept that s/he will not be abandoned by the clinician in the case of chronic or recalcitrant dermatological disorders (2). …

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