Adolecent Flashcards
At what age is delayed puberty in a girl?
At what age is delayed puberty and a boy
Girl: 13–14 years old
Boy: 14–15 years old
At what age is precocious puberty in a girl?
And a boy?
Secondary signs before eight years old
Secondary signs before nine years old
Describe SMR one in girls
Describe SMR to in girls
SMR one: basal growth 5–6 cm per year,boyish chest no hair
SMR to: accelerated growth 7–8 cm per year, rest bud present hair only along the labia
Describe SMR three girls
Describe SMR four in girls
Describe SMR five in girls
SMR three: pea coat velocity 8 to 10 cm per year, elevated breast contour, enlarged areola, curly hair at pubis, axillary hair, imagine a girl sitting on a three legged stool crying because she has hair in her armpit and has acne
SMR four: mound on mound. Dance hair none at the thigh
SMR5 stop growing at 16, rest again looks like tanner 3
Describe SMR1 in males
Describe SMR two in males
SMR1: small testicles, no hair, baby penis, basal rate of growth 5–6 cm per year
Smr 2: testicles and large, first sign of puberty, hair at base of penis
Describe SMR three in boys
Describe SMR four in boys
Describe SMR five in boys
Accelerated vertical and penile growth, gynecomastia, curly hair at pubis, think of the three stooges
SMR number four: Peak height velocity, 10 cm per year, no thigh hair, axillary hair, acne, body odor
SMR5: stop growing at about 17, facial hair,Gynecomastia goes away, thigh hair
Is it normal to have vaginal bleeding while in SMR to?
What should you think of in your differential?
No it is not
You should consider a foreign body such as toilet paper
Which two lab tests can be normally elevated during growth spurts?
Alkaline phosphatase
Hematocrit
What is the normal order of development of Secondary sexual characteristics in females?
In males?
Thelarche then adrenarche then Menarche, think TAM girls are tamer than boys
Testicular enlargement, adrenarche, Pinot enlargement, think TAP boys like to tap her
Which hormone causes the development of breasts, changing vaginal color and labial prominence
Estrogen
If you are presented an adolescent with breasts but no pubic hair, what should be your differential
Androgen insensitivity a.k.a. testicular feminization, someone carrying XY chromosomes
If you were presented with an adolescent female with a history of pubic hair but no preceding breast development what is the likely cause?
If a child has pubic hair, virilization and advanced skeletal maturation what is likely the cause?
Low estrogen
Androgen excess
If an adolescent presents with premature adrenarche, pubic hair with no breasts or no increase in testicular size, what test should you do first?
What should you do if this test is Within 1–2 years of chronological age?
Get bone age films
It is OK to observe, if the bone age films are not within 1–2 years referred to endocrinologist
If you are presented a short “girl “with no breasts or just buds with absent or scant pubic hair and no menses, what test should you get and what is likely the diagnosis
Get karyotype
Diagnosis likely turners syndrome
What are the two usual causes of breast masses in children?
At what time should these masses be checked with respect to menstruation
What imaging should be used to evaluate?
Fibrocystic change or fibroadenoma
At the end of menstrual periods, mammography is not needed until patients are much older
Ultrasound is used
How is fibrocystic change of the breast presented?
How do you treat it
It is bilateral and tender
Treat with NSAIDs, elimination of caffeine and possibly OCP
What is the most common breast lesion
They are _____ dependent
Fibroadenomas unilateral vs fibrocystic changes which is bilateral
Estrogen
How do you start to work out precocious puberty?
First examined for testicular/ovarian tumors
LH and FSH levels
Helicopter sound in girls
What lab tests are present in central precocious puberty?
In the peripheral precocious puberty?
Is the bone age on x-ray normal during both central and peripheral precocious puberty?
Central colon elevated LH levels and positive GnRH stimulation test, elevated LH: FSH ratio, study estrogen and testosterone levels
Peripheral normal LH and FSH, Pubertal estrogen and testosterone levels that are rising, abnormal pubertal development sequence
No, it is advanced in both
What are some causes of non-pituitary related/peripheral precocious puberty?
Tumors, congenital adrenal hyperplasia, McCune Albright syndrome, leydig cell hyperplasia
What are the criteria for precocious puberty girls?
What tests are ordered?
Breasts plus vaginal bleeding or accelerated growth
LH, FSH, estrogen, progesterone testing
How do you treat central precocious puberty?
How does this work?
With a GnRH analog called leuprolide
It suppresses LH and FSH released resulting in suppression of creation of steroids
What are two main terminal causes of precocious puberty in boys?
What physical characteristic must be present in order to choose purity as an answer in males?
What situation should you think of if there is small testes but evidence of hair, penile Marchman and/or growth spurt?
Elevated LH or Elevated hCG like in an hCG secreting tumor
There must be evidence of testicular enlargement, greater than 4 mL/2.5 cm
Think of a non-central and non-gonadal problem like CAH, virilizing tumors or exogenous steroids
Premature adrenarche or hair growth in boys is serious because it can be due to what?
If workout for premature adrenarche in a boy suggest an adrenal source what answer should you choose?
It can be due to CAH
You should choose CAH over adrenal tumor
What is the cause of congenital adrenal hyperplasia?
How do you diagnose it?
Is due to cortisol and aldosterone manufacturing problem in the adrenal gland due to absence of a negative feedback from low cortisol levels resulting in higher ACTH causing increased cortisol precursors and thus more androgens
Test for 17 hydroxyprogesterone which will be high
Is premature thelarche usually benign?
What test should you order if a girl has premature adrenarche? What would be a normal results of this test?
Yes, as long as there are no other signs of premature puberty such as menses or growth
Get bone age films and if it is within one year of the chronic logical age you can be observed
Define delayed puberty in girls and boys
If your FSH and LH levels are normal or elevated, what is likely the cause?
Lack of breast buds by 13 and girls, lack of testicular enlargement by 14 for boys
It is likely gonadal
Define primary hypogonadism, what are som causes
Define secondary hypogonadism, What are some causes
No response of the gonads to FSH and LH, these levels will be high, causes include receptor problems, absent gonads, biosynthesis problems, turner syndrome, Klinefelter syndrome
Secondary, FSH and LH have reduced or absent efficacy,FSH and LH levels will be low or normal, hypothalamus, pituitary, thyroid problems
Prolactinoma should be in your differential for a patient with what diagnosis? Why would this cause this diagnosis?
Delayed puberty, because prolactin suppresses GnRH secretion and decreases LH and FSH levels
Define constitutional delay of puberty
It is not usually treated with hormones but which one could be used?
Bone age films estimate an age that is younger than chronological age, height is normal but on a lower curve than expected
Treat with testosterone, not growth hormone
In hypogonadotropic ovarian failure, which 2 causes should be considered?
Define Kallman syndrome, What is the cause of it and what symptoms will be present
Poor nutrition or eating disorder
No gnrh, You will have anosmia, hypoplasia of the optic nerve, absence of the septum pellucidum, micropenis, all organs are midline structures, nose, pituitary, penis, optic nerve
Describe the basic work out of delayed puberty
Take a history, Bone age films, ultrasound if indicated, FSH, LH, estrogen/testosterone, TSH, free T4, prolactin, karyotype if there is primary hypogonadism
Up to a ___ year delay between bone age and chron Age is normal
Describe genetic or familial short stature
2 years
The child is born with normal length but height decelerates over the first two years of life to find the new curve, bone age matches chronological age
Define constitutional growth delay
Do you treat this?
There is normal growth until about one year, delayed bone age will mirror by age, look for a short child who is like matches with the bone age family
No you don’t need to
How does congenital growth hormone deficiency present
This is likely not the correct answer you should think of what other seven diagnoses instead
A bone age that is 75% of chronological age with a Decelerated growth rate with weight percentile that is greater than height percentile 
Crohn’s disease, hypothyroidism, genetic short stature, constitutional growth delay, turners syndrome, hurlers, hunters
What symptoms would you say to consider hypothyroidism as a cause of short stature?
What symptoms would you say to think CAH?
How about nutrition deficiencies?
Short, overweight, delayed donate with her without constipation, dry skin
Hyper androgynism, premature closure of growth plates, look for early puberty with accelerated growth but a short final height
Nutritional deficiencies will have bone age mirroring chronological age with the lower weight percentile and preserved height percentileBut these will become proportional if mount nutrition continues
How will Klinefelter syndrome present
How do you diagnose
Gynecomastia, small testicles, infertility, normal intelligent/mild ID
Chromosome analysis looking for XXY
How else might the test describe someone with tall stature and long arms and legs
Which cardiac problems are associated with Marfan syndrome
Which type of subluxation of the lens is only associated with Marfan’s? Subluxation is also associated with which other two diseases?
They are described as having a low upper to lower segment ratio
MVP, aortic dissection, MR and/or AR
Superior subluxation
Ehlers Danlos, homocystinuria
If you see a quick drop in weight without a significant drop in height, is this normal?
What are the three main causes of small head disorders
No, there is a severe underlying disorder such as G.I., renal or metabolic
Primary craniosynostosis, abnormal suture lines with normal brain, primary microcephaly, small head with abnormal brain, secondary microcephaly, normal sutures, abnormal brain due to some disease process or environmental exposure
In amenorrhea, what is the first thing to rule out
If the pregnancy is negative then move on to which test? How is this test resulted?
If progesterone challenge is positive which test do you get next?
If this test is low which to test do you get next
Pregnancy
Progesterone challenge, patient bleeds within two weeks of administration, this means there is plenty of estrogen but missing progesterone
Check LH level, if High think PCOS
If LH is low get prolactin and a TSH, if prl is high think prolactinoma
What are the main three causes of primary amenorrhea
How will androgen insensitivity present
Exercise induced amenorrhea, Turner’s, androgen and sensitivity
Genetically XY with breasts but no hair
How is secondary amenorrhea defined
What should be included in the differential
Absence of menses for three months and someone with previously normal periods or six months and previously abnormal.
Ascherman syndrome, intrauterine adhesions, cystic fibrosis, sarcoidosis, Tb, brain tumor, nutrition
If you’re considering anorexia as a cost for secondary amenorrhea what other three findings will hint toward this?
What is the first line treatment for PMS? The second line treatment?
Low heart rate, orthostasis, hypothermia
NSAID, Second line fluoxetine
Define dysmenorrhea, how is it treated
What is the cause of secondary dysmenorrhea
Painful menses with no mood component, treated with NSAIDs, this is due to prostaglandin E
It is due to a pelvic pathology like endometriosis, pregnancy, ectopic pregnancy
What Recreational drug can cause galactorrhea?
Levonorgestrol Can be taken up to how many days after sex to be effective?
Marijuana
Three days
What are two contraindications to doing a Pap smear?
When do you start doing Pap smears
Mucopurulent discharge suggesting STD due to Possible false positive, patient on her period
21
If a Pap smear shows ASC US, when do you repeat it? What if it shows it again?
If you notice anogenital warts in a patient younger than three is this normal? What if they present after three?
In one year, consider colposcopy if still positive after one year
This can be normal in less than three due to congenital transmission of HPV, if after three you need to think sexual abuse
What are the 20 types of HPV that causes cervical cancer the most
Condyloma acuminata is associated with what? Condyloma lata is associated with what?
16 and 18
HPV, syphilis
Which lab test support diarrhetic abuse
Which EKG findings can be associated with anorexia
Hypokalemia, alkalosis, high fractional excretion of sodium
ST depression, QT prolongation
What findings are associated with bulimia
Which electrolytes can be low in refeeding syndrome, what is the cause
Enamel erosion, enlarged parotid gland, elevated amylase, irregular menses, hypokalemic hypochloremic metabolic alkalosis, lanugo hair
Potassium, magnesium, especially phosphate, due to thiamine deficiency
Which two blood tests should be ordered for a painless scrotal mass
If either of these are high which tests should be done?
HCG and AFP
Ultrasound and CT of the chest/abdomen/pelvis
Which scrotal mass is painless, changes shape with position and Valsalva and is superior and anterior to the testes and transilluminate
It should resolve by what age? What should you do if it does not
Hydrocele
Buy one year, if not then refer to surgery
Which scrotal mass is painless, superior and posterior to the testicle and does not change with position, is nodular and does transilluminate
Is any treatment needed?
Spermatocele
No treatment is needed
Describe an inguinal hernia
What are some symptoms of testicular torsion
A painful scrotal mass that changes with position and does not transilluminate
Absence of cremasteric Reflects, increased pain when the scrotum is elevated
What findings are associated with torsion of the appendix testes or epididymis
How is this treated
The blue dot sign
NSAID 
How is epididymitis and orchitis differentiate
Which virus is associated with orchitis
Both are painful and may have a fever but there is no discharge and no dysuria with orchitis
Think mumps
What is the initial treatment for phimosis
Topical steroids
