Adolescent Medicine Flashcards
what age is considered early adolescence?
10-13 years
- Rapid changes in physical appearance (secondary sex characteristics) and behavior are major changes in early adolescence, leading to more self-consciousness and need for privacy
- More comfortable with members of same sex
- Body image and self-esteem fluctuate
- Peer relationships increasingly important
- Limited thought of future and if so, vague and unrealistic goals likely
what stage of adolescence is this?
early adol
- Struggle for autonomy and sense of identity are the major characteristics of middle adolescence
- High risk behaviors as a result of experimentation are common
- Intense emotions and mood swings
- Moves from concrete thinking to more abstract
- Self-centered
- Peers in…parents out
- History focuses on middle adolescent’s interaction with family, school and peers
what stage of adolescence?
middle adol - 14-16 y/o
- Individuality and planning for the future are the major characteristics of late adolescence
- Less self-centered and more caring for others
- Idealism with rigid concepts of right and wrong with moral reasoning
- More serious relationships
- Greater emphasis is placed on the late adolescent’s **responsibility for his or her health **
what stage of adolescence?
late adol - 17-21 y/o
Leading causes of morbidity and mortality of adolescent medicine?
- Automobile crashes (75% of all deaths MVA related)
- Homicide / Suicide
- Reproductive Health (STDs, unwanted pregnancies)
- Alcohol / Drug Use, tobacco use
- Obesity / Type 2 Diabetes
- Hypertension
when to screen kids for risk-tasking behavior?
how to discuss?
- all kids 10 and older
- Speak with them in the room with parents and also without parents if they prefer
- Confidentiality
Key characteristics in mature minors are?
their competence and capacity to understand, not their chronological age
Some issues cannot be kept confidential such as:
uicidal intent, positive HIV status, and disclosure of sexual or physical abuse
If you are unsure if disclosing confidential information is in question it is wise to ?
seek legal, ethical or social worker consultation.
Sexual education and birth control for adolescents?
- 6th grade in any public school but at any age in office
- Birth control - if demonstrates maturity. No minimum age for purchasing condoms
- HIV testing - no age limit
Drug related issues are screened when?
at any age, but 11 and older is key
three ways a child can become emancipated:
- get married
- join the military
- go to court and have the judge declare you emancipated
- over age 16 who has petitioned a court to be declared emancipated
- Physically and Financially independent of family
- Childbirth (does not automatically make them emancipated, but may apply)
- Child over age 14 who demonstrates maturity and decision-making capacity
- Intervention is neither a major one nor for the benefit of another
- In the case of an STD or treatment thereof
- Thorough documentation of the above in the medical record
what type of minor?
mature minors
4 categories of preventative services
- Screening
- Counseling to reduce risk
- Immunizations
- General health guidance: Even if parents accompany the adolescent to the appointment - ask the patient if ok to ask them to leave the room to discuss more private issues with the patient. BUT have chaperone for exam.
components to screen for
- Diet
- Exercise
- Seatbelts / Helmets / Texting
- Sleep
- Sexual behaviors
- Substance abuse
- Online behavior issues
- Bullying
- Sports
how to approach adolescents while screening
- Use a non-judgemental approach
- Open ended questions
- Be truthful and genuine
what to check for in immunizations
- Always check Hep A
- Tetanus may be given at age 10 or 11
-
Meningococcal vax
- Menactra, Menveo, Menomune - serogroup A, C, W and Y
- MenB (newest) - Trumenba and Bexsero - serogroup B -
HPV / Gardasil vaccine
- Originally 3 separate vaccines
- now if vaccinated before age 15 - may receive only 2 - one at initial visit and one 6 months later
components of anticipatory guidance
- Healthy diet
- Seatbelts / helmet
- Exercise
- Sleep
- Sexual behaviors
- Avoid substance abuse
- Online behavior issues
- Bullying
- Electronics - Limiting to 1-2 hours a day
- Sunscreen
- Bug spray
- Breast exams / testicular exams
depression/anxiety should be screened if any suspicion such as:
changes in activty, emotions, and behavior
mgmt for depression/anxiety
- Medication / and or counseling
- Lab studies
- Follow-up regularly
scoring of PH9 and GAD7 and their perspective tx?
Second leading cause of death ages 15 - 19 yo?
MC in which sex?
suicide - 90% have mental health issues
Boys > Girls
Boys 3X greater rate of completed suicide
Girls 2X greater attempts
most adolescents have what two mood disorders?
bipolar or depression
MC ways of suicide seen in adolescents?
- firearm
- suffocation
suicide RF
- Family hx of suicide or suicidal ideation
- History of adoption
- Male gender
- Parental mental health problems
- Lesbian, gay, bisexual, transgender, or questioning of sexual orientation
- History of sexual abuse
- Previous attempt
- Sleep disturbances
- Stressful life events
- Depression, bipolar, panic attacks, psychosis
- Substance abuse disorders
- PTSD
- Pathologic internet use
- NSSI - Non-suicidal self injury (cutting)
- Bullying
- Impaired parent-child relationship
- Living outside the home
- Difficulties in school, not attending school, social isolation
suicide mgmt
- Screening: Depression / Anxiety, NSSI, Social aspects (Bullying, family stressors, school, friends), Substance abuse
- Medication and counseling: Treat the underlying disorder; Document - NSHIATT; Close follow-up
definition of school avoidance?
- Missing 1 week or more of school for an illness which would not require serious treatment
- Continues despite parents and care providers encouragement to attend
- Excessive absences in the past or separation anxiety history
- Recurrent somatoform complaints
- Returning to school quickly should be emphasized - So overwhelmed with catching up they get more anxious
- Parents feel helpless in getting them to attend
- Homebound/ now virtual options
AAP recommends BP measurement with height for every child how old?
how often?
- >= 3 yo
- Yearly at WCC
- Every visit if RF or obese
dx elevated BP is based on ?
patient plotting in the >95% according to age, sex, and height
New standards now classify those >13 years as adult with elevation of blood pressure measurement of ?
> 130/80
Considered positive if elevated on 3 separate occasions at least 1-2 weeks apart
nml, elevated, Stage I, stage II BP for < 13 y/o?
- Nml - < 90th percentile
- Elevated - 90-95th percentile or between 120/80 and < 95th percentile (whichever is lower)
- Stage I- Between ≥95th and < 95th percentile+12 mm Hg or between 130/80 and 139/89 mmHg (whichever is lower)
- Stage II - ≥95th p+12 mm Hg or ≥140/90 mmHg
nml, elevated, Stage I, stage II BP for < 13 y/o?
nml - < 120/80
elevated - 120/80 - 129/80
Stage I - 130/80 - 139/89
Stage II - >140/90
diagnostics for Stage I HTN - if asx
- Repeat in 1-2 weeks but initiate lifestyle modification
- If still elevated at f/u - recheck again in 3 months w/ counseling on nutrition and lifestyle changes again
- If elevated at f/u in 3 months - order labs, radiographic workup, and begin medication (ABPM may be ordered via referral if available)
- Pt MAY participate in sporting activities
diagnostics for Stage II HTN - if asx
- Repeat in 1 week but initiate lifestyle modification
- If elevated at f/u - order labs, radiographic workup, and refer to specialist for ABPM
- Begin medication
- MAY NOT participate in sporting activities until cleared by specialist
- Elevated Blood Pressure - Workup
- additional for obese?
- CBC
- CMP
- UA
- Lipids
- Renal U/S - normal weight children >8 y/o or <6 y/o with any abnormal urinalysis or renal function
- Cardiac ECHO - LVH
- If obese (BMI >95%): HbA1C, AST/ALT - screen for fatty liver
- Other possible studies: TSH, Sleep study
mgmt for elevated BP
-
Medications
- ACE - Lisinopril MC
- ARBs - Losartan
- Thiazides - HCTZ
- CCB - Amlodipine -
Anticipatory Guidance
- Nutritional counseling and DASH diet
- Exercise -
Follow-up
- q 4-6 wks to titrate dose PRN, then q 3 mo
- Goal: SBP and DBP < 90th percentile or
< 130/80 if >13 y/o
Breast buds - onset of female breast development
Thelarche
Early pubertal changes around 10.5 years of age (appearance of axillary and pubic hair) and growth spurt
Pubarche
onset of androgen-dependent body changes such as body odor and acne and pubic hair increases
Adrenarche
Beginning of menstruation - starts about 2-½ years after onset of puberty
Menarche
tanner staging of girls and boys?
- Completion typically takes between 4-5 years
- Girls - 10.5
- boys - 11.5
precocious puberty - Secondary sexual characteristics starting before age ___ in Caucasian females or age ___ in African American or Hispanic females / < age ____ in boys
- 8
- 7
- 9
screen!
precocious puberty is idiopathic MC in who?
girls
definition of delayed puberty?
often associated with what deficiency?
tx?
- 12 - 13 years in girls for breast development (no menses by 16); 13 - 14 years in boys for testicular enlargement
- Typically associated with GnRH deficiency
- Exogenous testosterone or estrogen (boys >14 or girls >12 with no signs of sexual development)
- Benign symmetrical glandular breast tissue with no terminal alveolar development
- 65% males going through puberty
- Imbalance between androgens and estrogens
- bilateral but may be unilateral
- Tender to palpation
- Regresses spontaneously between 1 - 2 years (70%), and usually not past age 17 yo
- not greater than 4 cm in diameter
dx?
mgmt?
- Gynecomastia
- Watch and wait (12-14 mo); Persistent with psych trauma - surgical; meds controversial - testosterone, tamoxifen
w/u for precocious puberty
- Bone Age - XR of L hand and wrist to compare chronological age with skeletal maturity age
- LH
- FSH
- DHEA-S - sex steroid hormone exclusively of adrenal origin
- Estradiol (females) - sex steroid hormone
- Testosterone (males)
- Prolactin - pituitary hormone which can detect adenomas
- MRI brain - evaluate for CNS lesions
- Other testing - GnRH stimulation test, HCG, TSH, pelvic U/S or testicular U/S
Sexual development meaning in boys and girls:
increased testicular size in boys
breast size in girls
w/u for delayed puberty
- CBC, ESR, CMP
- Estradiol (females)
- Testosterone (males)
- Prolactin
- TSH
- DHEA-S
- Bone age studies
- MRI brain
wha number of high school teens admit to being sexually active?
how many will contract an STD? which are MC?
- ½ of HS teens
- ¼ - HPV, chlamydia and trichomoniasis
how to address sexual activity with HS teens?
- Screen all teens alone in the room without a parent present if possible
- Ask open ended questions and ensure confidentiality
- urine screen for gonorrhea and chlamydia yearly on any teen who has been sexually active in the past
- Screen any teen for pregnancy before starting any type of OC
- Complete urine pregnancy test on any adolescent female ℅ amenorrhea or persistent vomiting, despite disclosure of not being sexually active
what age to start cervical-cancer screening? (unless started to have sex much sooner or have HIV and are on antivirals)
21
what age to stop cervical-cancer screening?
65
what age range recommended to get pap test q3yrs
21-29
what age range is recommended to get either a pap test q3y or both the HPV and the pap test q5y
30-65
for all ages, when can you skip the annual pelvic exam?
if no sx and not pregnant
tanner stage 1 for female, male, both?
female - preadolescent
male - childhood size
both - none
tanner stage 2 - female, male, both?
female - breast buds
male - enlargement of scrotum/testes
both - sparse, long, straight
tanner stage 3 - female, male, both?
female - areolar diameter grows
male - penis grows in length, test continue to grow
both - darker, curling, increased amount
tanner stage 4 - female, male, both?
female - secondary mound; separation of contour
penis grows in length/breadth; scrotum darker, testes enlarge
both - coarse, curly adult type
tanner stage 5 - female, male, both
female - mature female
male - adult shape/size
both - adult, extends to thighs
