5: 16-year-old female health maintenance visit

Question 1

Signs of Hypothyroidism in the Adolescent

Answer 1

• Cold skin
• Slowness
• Fatigue
• Preferring hot weather to cold
• Doing poorly at school
• Coarse hair

Question 2

Typical signs and symptoms of infectious mono

Answer 2

extreme fatigue, pharyngitis, and lymphadenopathy

Question 3

Menses in Adolescence important information to gather includes

Answer 3

• Timing (frequency) of periods
• Duration of bleeding
• Whether the last menstrual period was normal.

Question 4

Identification of Depression in Adolescents

Answer 4

• mood swings
• adjustment reactions
• need for evaluation
• screening for suicidality

Question 5

s/s of depression do not include:

Answer 5

Early morning waking; difficulty falling asleep at night

Question 6

Signs Associated with Anorexia

Answer 6

• bradycardia
• electrolyte disturbances
• compromised cardiac function

Question 7

Signs Associated with Bulimia

Answer 7

Compared with anorexia, bulimia can be more difficult to diagnose because of lack of weight loss in early stages. Sometimes, only secondary effects are manifest, such as dental decay (from stomach acid) or finger trauma from self-induced vomiting.

Question 8

There are many factors to consider when evaluating a decline in an adolescent’s school performance. Among them

Answer 8

• Medical conditions, such as hypothyroidism
• A significant loss, such as the death of a close relative
• Psychosocial or mental health issues, such as drug abuse and depression

Question 9

Sexual-maturity Ratings (SMR), or Tanner Stages: GIRLS

Answer 9

Girls start puberty between 8 and 13 years of age

• -Breast buds appear (age 10-11 years), then
• -Pubic hair appears (age 10-11 years)
• -Growth spurt (age 12 years)
• -Periods begin/menarche (age 12-13 years)
• -Attainment of adult height (age 15 years)

Question 10

Sexual-maturity Ratings (SMR), or Tanner Stages: BOYS

Answer 10

Boys start puberty between 10 and 15 years of age

• -Growth of testicles ( age 12 years)
• -Pubic hair appears (age 12 years)
• -Growth of penis, scrotum (age 13-14 years)
• -First ejaculations (age 13-14 years)
• -Growth spurt (age 14 years)
• -Attainment of adult height (age 17 years)

Question 11

Constitutional Short Stature

Answer 11

“late-bloomer” in puberty, but will attain a normal adult height-just later than his or her peers.

Question 12

vWD Epidemiology and Inheritance Pattern

Answer 12

• vWD is the most common hereditary bleeding disorder.
• Occurs in approximately 1% of the pop.
• For most families, it is transferred to children via autosomal dominant inheritance with variable penetrance (Type 1 and all Type 2 subcategories).
• The much less common Type 3 is inherited as autosomal recessive.

Question 13

vWD symptoms

Answer 13

• Ecchymoses (small hematomas in areas of trauma)
• Epistaxis
• Menorrhagia (why vWD is diagnosed more often in women than men)
• Bleeding post-tonsillectomy and dental extractions
• Gingival bleeds
• In the absence of major trauma, bruising in non-exposed areas (buttocks, back, trunk) needs to be thought of as abnormal.

Question 14

vWD Classification

Answer 14

Type I vWD is the most common type (70%) and the mildest. The bleeding generally is not life-threatening.

Question 15

most sensitive indicator of vWD

Answer 15

careful clinical hx

Question 16

The laboratory diagnosis of vWD can be challenging

Answer 16

• Many textbooks state that a prolonged platelet function or bleeding time and mild prolongation of the aPTT point to the diagnosis of vWD.
• However, the aPTT may be normal and the patient will still have vWD.
• To confirm vWD, check the von Willebrand’s factor antigen and/or platelet function analysis and factor VIII levels

Question 17

HEEADSSS Mnemonic for Adolescent Screening

Answer 17

an enhancement of the social history in adolescent care visits that typically is obtained after the family history and before the review of systems

Question 18

HEEADSSS stands for

Answer 18

H - Home
E - Education and employment
E - Eating disorder screening
A - Activities
D - Drugs
S - Sexuality
S - Suicide risk and depression
S - Safety (fights, car, weapons)

Question 19

Interviewing Adolescents

Answer 19

• When interviewing adolescents, it is important to separate them from their parents/caregivers and conduct part of the interview with the adolescent alone.
• Physicians should start this process at an early age (9 to 10 years) and tell the patient and parent that this is their regular practice, to be continued in adolescence.
• It is unusual for the parent not to accept this. However, if the parent says, “We have no secrets; you can discuss everything with me,” you could then respond, “At this age, there are sometimes questions that both the parent and the adolescent may wish to discuss alone with me.” This usually works.
• Don’t forget confidentiality.

Question 20

Chaperones

Answer 20

must be used for an opposite-sex patient when doing any genital exam or for breast examination in females. (Many providers prefer a chaperone for any genital or breast exam, regardless of the genders of the provider and patient.)

Question 21

Treatment of Eating Disorders

Answer 21

• Finding community-based therapists and nutritionists skilled with working with adolescent and their families or an eating disorder center or other facility skilled in management is essential to prevent death and to begin the difficult path toward correction of the altered body images.
• *Remember that it is NOT just girls who can be afflicted with anorexia; approximately 25% of cases happen in boys.

Question 22

Treatment of von Willebrand’s Disease

Answer 22

most often consists of intranasal or intravenous desmopressin.

Question 23

Differential Diagnosis for Fatigue in an Adolescent Female: Anemia

Answer 23

• Anemia should be a consideration in an adolescent female. This can be caused by:
• -A bleeding d/o (may result in heavy periods and significant fatigue)
• -Iron deficiency (typically not as much fatigue associated, as a slow decline allows the body to compensate, such as by increasing blood volume; eventually the patient will be symptomatic, but it may be a while)
• As long as the anemia is not associated with neutropenia or thrombocytopenia, the pt’s ROS will also be negative.
• A Fhx of anemia supports this diagnosis.

Question 24

Differential Diagnosis for Fatigue in an Adolescent Female: Bleeding d/o

Answer 24

• -A bleeding disorder leading to anemia is a more specific diagnosis than just anemia.
• -Fatigue is a common problem with bleeding disorders. Because of the much more rapid loss of hemoglobin, fatigue is more likely to happen with a bleeding disorder than chronic anemia.
• -Bleeding d/o commonly cause menorrhagia. As many as 1 in 5 women w/ heavy prolonged periods have a bleeding d/o
• -A patient with a bleeding d/o would have a negative ROS unless there is severe systemic illness leading to DIC
• -Bleeding d/o are confined to d/o of platelets and clotting factors.

Question 25

Differential Diagnosis for Fatigue in an Adolescent Female: Hypothyroidism

Answer 25

• Thyroid disorders commonly cause menstrual abnormalities.
• Hypothyroid is associated with menorrhagia and shorter menstrual cycles.
• Other common symptoms of hypothyroidism include constipation, weight gain, and decreased appetite.

Question 26

Differential Diagnosis for Fatigue in an Adolescent Female: Depression

Answer 26

Fatigue may be a symptom of depression

Question 27

Differential Diagnosis for Fatigue in an Adolescent Female: Substance abuse

Answer 27

Declining school performance may be an indicator