Adolescent Medicine Flashcards
when is the adolescent period
what are the four “Tasks” of adolescents
Adolescents
- defined as the ages between 10 afn 19
- transition to adulthood:can be seen into early 20s
Tasks
- complete puberty and somatic growth
- develop socailly, emotionally and cognitvietly
- move from concrete to abstract thinkinig
- establish seperate identity from fmily
- prepare for career
define the following
thelarche
pubarche
menarche
adrenache
Thelarche
- development of the breast tissue: usually first sign of puberty in females
Pubarche
- pubic hair development with OUT breast development in females
menarche
- onset of menstruation
adrenarche
- adrenal glad “awakens” & leads to increads adrogen production in men and women
- develop pubic hair, oily hair/skin and body odor
Physiology of Puberty male & female
Male
- at puberty = inhibition of GnRH is removed: allows for pusatile release of the hormone
- GnRH triggers FSH and LH
- LH: to the lydig cells: makes testosterone
- FSH: to the sartoli cells to make sperm
female
- GnRH inhibition release at puberty: increase in pusatile release
- GnRH triggers FSH and LH
- FSH: stimulates ovarian maturation, granuolsa cell function & therefore estradiol production
- LH: stimulates ovulation, corpus leutem creation & progesteron release
- estradiol: initially inhibits FSH and LH release as its bein produced
- then later: the estradiol becomes stiulatory and teh cyclic pattern begins
Abnormal Puberty
Delay v Percious definitions
Abnormal Puberty
- variable onset based on ethnicity: black chidlren tend to have puberty happen earlier
Delayed PUberty
- female: no breast tissue development by age 13; or no menarche within 4-5 years after puberty (breast tissue) arises
- males: no onset of testicular enlargement by age 14; maturational arrest
Precious Puberty
- onset of puberty at least 2 SD before the expected (calculated with ethinictiy)
- this generally triggers endocrine referral
- onset of puberty: less than 8 in females
- onset of puberty: less than 9 in males
reasons for Delayed Puberty & Precious Puberty
Delayed Puberty
- constitutional delay
- anatomic abnormalities
- hypogonadism: turner syndrome, premature ovarian failure, galctosemia
- central hypogonadism: hypothalmic/pituitary issues, cushings’, hypothyroidism
Precious Puberty
- centeral reasons: CNS tumore, hydrocephalus, radiation, trauma, mcCune Albright, hypothyroidism (decreased FSH,LH)
- peripheraly: (increased FSH, LH) : adrneal tumor, pituitary tumor, exposure to exogenous hormones, ovarian cysts, testicauarl tumor
- COVID-19 or idopathic!
Somatic Growth for Male and Female in adolscence
Females
- weight can double during puberty
- height increases by 15-20%
- muscle mass and stregth increases
- lean body mass decreased to 75% of total body weight
Males
- weight doubles
- height increases 15-20%
- muscle mass and stregnth increase
- lean body mass INCREASES to 90%
reasons for adolsecent mortality
and morbidity
Mortality
- leading cause of death in 2022: GUN VIOLENCE
- in 2019 it was unintentional death
Morbidity
- most adolescents in good or excellent health: so they unfortunately dont come to yeraly checks and we cant provide preventitive and primary interventions!
major morbidities include
- unintended pregnancy
- STIs
- substance use
- depression
- smoking
- violence
-
clinical facotrs: only a few locations iwthin training specifically for adolescnt medicine
approach to the visit with adolescent pt.
when to interview alone
remember they are the primary pt. introduce self and engage wtih them first before asking them who is in the room with them
- take time to listen, show genuine insterest
- pay close attention to body language
- use open ended wuestions, allow long periods of silence (12 seconds or more!!) to answer
when to interview alone
- begin introducing the idea at age 11
- should begin to occur at 12-13 years old
- get parent out of room: while child is changing into gown and explain what will happen, also time for parent to voice concerns
Confidentialtiy in the adolescent exam
what to speak about
when and what would be told to parents
Confidentiality
- basic right and importatnf or relationship!
- address this at beginning o visits
Discussion
- ANYTHING!!!
- Sexualatiy: testing, activity, contraception, LGBT,
- sexual victim : most states require this to be reported to law or parents or botH
- drinking/drugs/tobacco use
limitations to confidentiality: when it needs to be shared
- life-threatening concerns
- hurting self or others
- intention to hurt self or others
- these should be shared with others
Factors permitting health care for minors withOUT parental consent
this varies by state but on average
- married
- miliarty
- bearing a child of their own
- reporductive care services (activity, STIs, abortion, contraception)
- independtly living (emancipated)
- reproductive care
- mental health care
- substance abuse evaluation
- life-threatening care: treat then contact pt.
this can be challenging becuase of EMR…
- if getting STI testing; this can come up on paretns insurance and EMRs/portol access
Questions to be asked in the psychosocial history for the adolsecent
HEEEADDSSS(S)
H: home
E: education
E: employement
E: eating
A: activities
D: drugs/alcohol
D: depression/suicide
S: sexuality
S: safety
S: spirituality
(S): Screens and social media!
ask these questions with open-ended ones, “tell me about your home life, what do you enjoy or dislike about school”
Home Assessment Questions
Education Questions
Employment Questinos
Home
- who do you live with
- where (house v apt)
- share room
- relationship with parents/sibilins
Education
- what school and grade
- class types
- worst and best subeject & grades
- days missed
Employment
- do you work ? how often and what type
- what do you want to do when older?
Eating Questions
disorders to be aware of
Eating
- how do you feel about your weight? wish you weighed more or less?
- what do you eat in a typical day?
- “perfect weight”
watch meal skipping!! and controlling behaviors
Disorders to be aware of
- anorexia nervosa and bulimia are seen most commonly in teens (F>M) (think of gymnasts and wrestlers)
- relative energy deficiency syndrome (female athlete triad) : OP, disordered eating, menstrual irreg.
- binge eating disorder on the rise
Adolsecent Obesity
Obesity
- consider to be 120% of the 95th percentile BMI curve OR
- BMI > 40 (class III obseity)
rising: 21% prevelence in those 15-19
- adolsecents have increased autonomy over what they eat
Treatment
- lifestyle interventions!! early and start them
pharmacotherapy :
- semaglutide or liraglutide for 12+
- metformin 6+
- phentermine 12+ short term only
- phentermine/topier. 12+ short term
bariatric surgery
- watch with consent to lifelong adhearnace to changes
Activity Questions
Activity
- spend free time, do for fun
- excel at? sports? how often
Drugs Questions
alchol and substance abuse: screeners& assessment tools
Drugs
- do your friends do drugs, alchol or tobacco
- do you? kind, how much , how often
- anabolic steroids
Screeners: alcohol and substance use
screeners
- screenign to brief intervention (S2BI)
- BSTAD
- NIAAA
if these go positive= follow up with assessment tools
assessment tools
- CRAFFT : considered high risk if 2+
- AUDIT : 0-7 low risk, 8-15, at risk, 16-19 high risk, 20-40 PROBABLE substance use disorder
Prescription Drug Abuse: on the rise
- stimulants
- opioids
- benzos
- getting from others/freinds/sold
Depression and Suicidality Questions
Depression: screening
Questions
- how do you usually feel: happy,sad, etc.
- what makes you feel stressed
- how do you relieve stress
- have you thoguth about killing or hurting yourself
Adolsecent Depression
- increasing prevelence
- of those affected, only 40% actaulyl diagnosed and treated
- recommendation: screen annually : PHQ:9 for teens
Risk Factors: Depression
- high funtioning autism
- acedemic difficulties
- body dissatifaction
- negative thinking
- loss of loved one
- low SES
Suicidality
- highest rates in younger pt.
- 20% of high schoolers have thoughts!!!
- known the 988 hotline number
Depression : Treatment in adolescents
Treatment
- combination of psychotherapy and pharmacotherapy is best
- CBT = choice of psychotherapy
- can do either type alone
upon initiation of the pharmacothearpy: watch inital increase in suiciadlity for first weeks
medication choices
- sertraline best evidence: approve 6+
- escitalopram (12+) and citalopram (7+)
- little evidence for SNRIs
Adolscent Sexuality Questions
Dicussion topics
non-coital sexual behaviors
Sexual orientation
Questions
- females: through menstrual history
- ever had the kind of sex: penis-vagina, mouth on penis, mouth on vagina, penis in rectum
- how old, how often, pain?
- satifised with partner
- forced into it?
Things to Dicuss
- puberty/development
- postponing coitus
- safe sex practices
- family planning
- sexual victim
- screening for STIs
- contraceptive rx.
- psychosocial support
Non-Coital Behaviors
- STi risk with these still, HIV can happen
- remember HPV!!
- oral-genital does not pospone intercourse
Sexual Orientation
- valid!! and health and natural dvelopmental outcomes
- ensure proper access to care
high risk for
- disapproal from society
- poor access to supportive care
- depression/suicide
- sexual victim
sexuality and the media
Direct relationship between viewing sex on the media and adolsecent sexual behavior!
online disinhibition can lead to divulging personal information more than if they were face to face
sexting: lots of pts. do these: be aware
media can be helpful for providing proper information about sex ed!
STIs in Adolscents
STIS
- about 1/2 the new infections are from 15-24 year olds
- provide eduation about safe practices
- condoms!!
- discuss use of the IUDS, implantables, pils, etc.
- advise against withdrawal method and surgical sterilixation
Emergency Contraception
- can get progesteron based pill: 50 bucks or free in some places
- O-pill: OTC contraception : but lost opportuinty for education!
Adolscent Pregnancy
higher rates of waht
whos at risk
Teen Pregnancy
- declined but still happen
- less liekly to access prenatal care: leads to poorer health outcomes
Higher rates of
- postpartum depression
- PTSG
- suicidal tendiencies
- failure to finish high school
Those at risk for adolsecent preg.
- poverty
- risky behaviors
- early initiation of sexual actvity
- parent or sibiling with hx. of teen preg.
- adverse childhood experiences
Adolscent Pregnancy
how to evaluate
sexual victims
Evaluate
- ask FDLMP at every female visit
- pregnancy test: in all eval. of amenorrhea
Assist
- inform adolescent of pregnancy in private
- deterime if sexual victim
- advise of all options
Teach
- normal childhood developmen
- encourage parenting
- infant safety
- watch PP depression
- teach grandparents modern infant care
- encourgae yougn parent to continue education
- watch for behavioral issues in infant
Sexual Victimization
- males and females at risk
- adverse childhood expereinces increase risk
- be aware: statutory rape and reporting laws in your state
- be on look out for survival sexand sex trafficking
Termination of Pregnancy
laws
Laws
- vary by state
- in PA: those 18+: leagl up to 23 weeks
- under 18: need a judical bypass if wanting to terminate without parental consent
Safety Questions
spirituality
Screens and socidal media
Questions
- protective sports gear
- victim of violence
- bullied?
- access to weapons/gun in home
Spirituatliy
- religion?
- how do beliefs influence health? drugs/alchol/sex/contraception
Screens
- hours of Tv weekly
- horus a week on computer
- hours a week on social media
PE of the adolescent exam
Vitals
- normal parameters by age
- generally 135/85 is abnormal
- follow growht by curves and body habitus
- sexual maturity ratings
head to toe exam specifically noting
- obseity/underweight
- acne
- scolisis
- gynecomastia
Sexual maturity Rating Male and Female
Male
- at stage 3: peak hegith veolcity, spermache, penile growth
- at stage 4: peak height, facial hair and voice chnage
- stage 5: mature
Female
- stage 2: subareolar buds, peak hegiht velocity
- stage 3: breasts enlarge, darker hair
- stage 4: meanarche
- stage 5: mature
Gynecomastis in males on PE
Gynecomastia
- can be in 40% of males that are noramlly developing : resolves in 2 years
Reasons for referral
- features of klienfelters, liver or testicular disease
- gynecomasi lasting longer thatn 2 yeras
- rapidly delveoping
Alwasy do testicualr exam
Immunizations for adolscents
Flu : annually
Covid
MenACWY: 1 dose at 11-12, 2nd dose at 16
Tdap booster: 11-12 years
HPV: as young as 9; usually 9-14, 2 dose 6-12 months apart
if late on HPV: get 3 doses
High risk (immunocomp.)
- HiB
- PCV13
- PPSV23
- Men B
