3.4 Adolescent, Adult, and Geriatric Assessment

Quick Answer: After the pediatric bands come adolescent, young adult (including late adolescents and emancipated minors), adult, older adult, and frail elderly. Interview adolescents with HEADSS and know that confidential sexual, mental-health, and substance services are state-specific. Clear athletes with the AHA 14-element history; do not order a screening ECG on every healthy teen. In older adults, use the geriatric 5 Ms, Beers, frailty (not age alone), a polypharmacy count, and advance directives as assessment — not paperwork you will 'get to later.'

The FNP exam will hand you a 16-year-old in a football physical, a 19-year-old who aged out of pediatrics, a 48-year-old with three jobs, and an 84-year-old whose daughter 'just wants the medicines refilled.' Each band has must-not-miss assessment items. Chronologic age is the starting label; function, consent status, and frailty finish the sentence.

Adolescent assessment — HEADSS and confidentiality

HEADSS is the working frame:

• Home — who lives there, violence, food, a locked bedroom door, a trusted adult
• Education / employment — grades, skipping, IEP or 504, after-school job
• Activities — sports, friends, social media, connectedness versus isolation
• Drugs — vaping, alcohol, cannabis, leftover pills, peer use
• Sexuality — partners, practices, contraception, coercion, identity if the patient offers it
• Suicide / safety — mood, self-harm, guns, fighting, driving

Some mnemonics add Eating and a second Safety. The exam cares that you interview the adolescent alone for part of the visit, that you explain confidentiality and its limits (harm to self or others, abuse) before the sensitive questions, and that you do not take a sexual or substance history with a parent as interpreter.

Confidential services versus parental rights vary by state. All states allow some form of minor consent for STI evaluation and treatment. Many allow minors to consent to contraception. Mental-health and substance-use consent thresholds differ widely. Say that on the exam. Do not invent a single national age at which every adolescent's entire chart becomes secret, and do not assume a parent may hear every word of a 16-year-old's visit in every state.

Sexual health in this band is the 5 P's plus coercion and trafficking clues, last menstrual period, and pregnancy intention. Offer screening that matches practices, not a one-swab ritual.

Vaping is now the default inhaled-risk question. Ask product, frequency, nicotine versus cannabis oil, and respiratory or gastrointestinal symptoms that raise concern for lung injury. 'I do not smoke' is not a vaping history.

Mental health peaks in adolescence. Pair HEADSS with PHQ-2/9 or a validated adolescent depression screen, an anxiety screen when indicated, and a firearm question when mood is low. A sports physical is a mental-health visit wearing gym shorts.

Sports preparticipation — AHA 14-element, not a reflex ECG

The AHA 14-element assessment is a focused cardiac history plus four physical items. History includes exertional chest pain, unexplained syncope or near-syncope, excessive exertional dyspnea or fatigue, a prior murmur, prior elevated blood pressure, prior restriction from sports, prior cardiac testing, premature sudden death in the family, disability from heart disease in a young relative, and a family history of hypertrophic or dilated cardiomyopathy, channelopathy, Marfan syndrome, or clinically important arrhythmia. Physical items are a murmur (supine and standing, with Valsalva), femoral pulses (or brachial-femoral delay), Marfan stigmata, and brachial hypertension.

A screening ECG is not routine for every U.S. athlete when that history and exam are negative. Some European societies and some individual U.S. programs add ECG; the exam-safe FNP position is targeted testing when the 14-element screen is positive, not a universal echo-and-stress-test package for varsity clearance. A personal history of unexplained syncope during a sprint is an ECG-and-referral finding. A healthy 16-year-old with a negative screen is not.

Noncardiac clearance still matters: concussion history and current symptoms, a single kidney or single eye in a collision sport, poorly controlled asthma, and musculoskeletal readiness. Function, again, changes clearance more than the jersey number.

Young adult, late adolescent, and emancipated minors

Transition from pediatrics is an assessment, not a scheduling nuisance. Who is the adult clinician of record? Have records moved? Does a young adult with intellectual disability have a guardian, a supported-decision-making arrangement, or the legal right to consent? A 19-year-old who still uses a parent portal for every result has an unfinished transition.

Contraception and a reproductive life plan belong in every capable young-adult visit until the patient is finished with fertility: Do you want pregnancy in the next year? If not, what method matches medical eligibility, access, and privacy?

Cervical screening start. USPSTF starts cytology at age 21, regardless of sexual debut, and does not start at 16 merely because the patient is sexually active. ACS 2020 prefers primary HPV testing beginning at 25. Know both; the commonly tested primary-care start remains 21 under USPSTF, and starting Pap testing in early adolescence because of sexual activity is the classic wrong answer.

Lipids once in late adolescence or young adulthood follows Bright Futures / NHLBI timing: a universal screen roughly between 17 and 21, in addition to the 9–11-year screen, and earlier if family history suggests familial hypercholesterolemia. USPSTF finds insufficient evidence for universal screening under 20; AHA/ACC begin using a lipid value as part of adult ASCVD risk at 20. Teach the pediatric-to-adult handoff screen as 'once in this window unless risk is high,' not as an annual panel from age 18 forever.

Other young-adult assessment that is easy to skip: HIV at least once (USPSTF 15–65), hepatitis C once at 18 or older, mood and substance use (incidence is high), and occupational start-up risks in first jobs (needlesticks, solvents, night shift).

Consent nuances the FNP must not flatten. Legal adulthood is 18 in almost every state. Emancipation commonly follows marriage, active-duty military service, or a court order; a few states also treat a self-supporting minor living apart from parents as emancipated. A married 17-year-old presenting alone for contraception is often able to consent as an emancipated minor, but you still confirm the state rule. A pregnant or parenting minor often may consent to care for herself and her child even when she is not fully emancipated for every other decision. A late adolescent who is 18 is an adult — the parent in the waiting room does not automatically receive the visit summary. HIPAA and state minor-consent statutes are not the same document. When the vignette says 'varies by state,' that phrase is the scored answer, not a dodge.

Adult assessment — occupation, cardiometabolic load, cancer readiness, reproductive life plan

In established adults the comprehensive visit is no longer a milestone checklist. It is four questions:

1. Occupational. What do you do for 8–12 hours, and what can it injure? Lifting, solvents, shift work, sitting, sun, noise, and job insecurity all change pretest probability.
2. Cardiometabolic. Blood pressure, tobacco, BMI, glucose or A1c, lipids, and — from the 40s — a formal ASCVD-risk conversation. Sleep apnea clues belong here.
3. Cancer-screening readiness. What is due (cervical, breast, colorectal, lung if pack-years qualify, and shared-decision prostate conversations when appropriate), what the patient will actually complete, and which SDOH barrier last blocked the test.
4. Reproductive life plan until menopause or permanent sterilization, plus peri-menopause symptom and bleeding assessment when that age arrives.

An adult who 'feels fine' with a 22-pack-year history, a desk job, and no colon screening after 45 has a failed assessment if you only refill the antihistamine.

Older adult and frail elderly — 5 Ms, Beers, frailty, directives

Age 65 is a billing convenience. Frail elderly is a clinical state. Structure the visit with the geriatric 5 Ms:

Beers Criteria (American Geriatrics Society) are an assessment of medicine risk: potentially inappropriate medicines such as first-generation antihistamines, benzodiazepines, strong anticholinergics, sliding-scale insulin, and some sulfonylureas (for example glyburide). Finding a Beers medicine on the list is a functional-risk finding, not automatically a same-day stop without a taper plan.

Frailty phenotype versus clinical frailty. Fried phenotype = unintentional weight loss, exhaustion, weak grip, slow walk, low activity; three or more = frail, one or two = prefrail. The Clinical Frailty Scale is a 1–9 global judgment that already includes function (from very fit to terminally ill). Use one of them. Do not call every 80-year-old frail and do not call a 70-year-old with five phenotype features 'just older.'

Polypharmacy count is an assessment vital sign. A common threshold is five or more scheduled medicines, but the number only starts the reconciliation: indication, duplicate classes, last fill date, and who actually administers the doses.

Advance directives are assessment, not only planning. Does a document exist? Who is the proxy? Is there a MOLST or POLST? Has anyone asked what matters most if the patient cannot speak? Recording 'full code, not discussed' after a 40-minute visit is an incomplete geriatric assessment.

Must-not-miss items by official age band

Vignettes

A 16-year-old is on the schedule for a sports physical. Dad is in the waiting room and wants to sit in. After you explain confidentiality, the teen reports daily nicotine vaping, a new sexual partner without condoms, and two weeks of passive death wishes without a plan. The AHA 14-element history and exam are negative. Assessment problems: you must see the teen alone; state law governs what you can withhold from dad about sexual health and what you must share about suicide risk; STI testing and a mental-health safety plan are today; sports clearance can proceed from a cardiac standpoint without a screening ECG; vaping is not 'nonsmoker.'

A 17-year-old who is married presents alone and asks for contraception. Marriage is a common emancipation pathway, so she often may consent, but the scored move is to apply state minor-consent and emancipation rules rather than a national slogan.

An 83-year-old 'medication refill' arrives with her son. She takes 11 medicines including diphenhydramine and glyburide, has lost 8 pounds without trying, walks slowly from the chair, and has no identified health-care proxy. This is frail-elderly assessment: phenotype-positive, Beers risks, no 'matters most' data, and a plan that cannot be another 90-day refill without a 5 Ms review.