Adolescent Medicine Flashcards
Changes in physical growth
Average growth spurt 2-3 yrs, controlled by GH (insulin, thyroid, sex steroids also influence. 50% body weight and 25% height gained in spurt, 18-24 months earlier in females
Genitalia/Secondary sex characteristics
3-4 years of puberty,
Adrenarche (adrenal androgen synthesis)- 2 years before HPG
True puberty when gonaotropins increase
Physical changes in male puberty
Testicular enlargement @11-12 y/o
Facial/armpit hair 2 years after pubic hair begins
Female physical changes
Thelarche @ 9.5 years
Pubarche
menarche 2-3 years after thelarche, 12.5
Tanner stages (male)
1- preadolescent, no pubes
2-testes larger, downy hair
3-testes even bigger, penis longer, darker/coarse hair
4-darkening scrotal skin, big/wider penis, glans develops, hair over symph pubis
5-adult…hair to medial thigh
FSH
M- spermatogenesis
F-ovarian follicle development, ovarian granulosa cells make estrogen
LH
M- induces testicular Leydigs to make testosterone
F- stim ovarian theca cells make androgens, corpus luteum makes prog, midcycle surge in ovulation
Testosterone
Increase linear growth/muscle mass, penis/scrotum/prostate/seminalvesicles, hair growth, deepns voice, increases libido
Estradiol
M- increased rate epiphyseal fusion
F- stim breast develop, trig midcycle LH surge, stim lab/vag/uterine development, prolif endometrium, low level stim linear growth, high level => g-plate fusion
Progesterone
Converts endo to secretory endometrium
Adrenal androgens
M/F- stim pubic hair + linear growth
Tanner Females
1-preadolescent, no hair
2- elevation of breast/nipple projections, sparse downy hair on labia
3- enlarged breast, areola enlarges, dark/coarse/curly hair
4- areola/nipple project to form secondary mound, cover pubic symphysis
5- only nipple projects, hair to thigs
Early adolescence
10-13 years, Early shift to independence from parents, less interest in fam activities, mood/behavior changes, worried abt body changing, same-sex peer relationships, beginning of abstract thinking, lack of impulse control
Middle adolescence
14-17 years
increased parental conflicts, less worried abt pubertal changes, but trying to look good
Intense peer group involvement, romance starts
Increased abstract reasoning and risks
Late adolescence
18-21
Self as distinct from parents, more likely to seek advice from parents, comfortable with own body image, shared intimate relationships, abstract thought processes, less risks, articulate goals
HEADS/SHADESS
home, education and employment, activities, drugs, sexual activity, suicide/depression
Physical exam for adoescent
Height, weight, bp, pulse, hearing, vision, skin (acne/fungal), teeth (malocclusion/hygiene), thryooid, back (scoliosis), tanner stage, teach testicular exam, pelvic exam if sexually active or sx or 18
Immunizations
Tet/dipth booster between 11-12 y/o and then every 10 years
MMR + hep B if not given before adolescence
Hep A if in endemic area
Varicella- if kid never got chickenpox
Labs
Hb, HCt, UA, cholesterol/fasting liid panel, HIV is hx, TB test, if active, STI testing, annual chlamydia test
Depression
Epi- 3rd leading cause of death, 5% geens clinically depressed, girls 2x more than boys
Risks- fam/peer confict, loss, substances, divorce, learning disable, abuse, fam hx, illness
Clin- behavioral sx (miss school, act out, lack of interest, withdrawn, substance), physical (ab pain, h/a, wl, overeat, insomnia, anxious), psych signs saddness
Dpression criteria
5/9 almost every day for at least 2 weeks, can’t function normally:
Depresed/irritable mood, diminished interest/pleasure, weight change, sleep change, psychomotor change, fatigue, worthless, can’t concentrate, suicide thoughts
Dysthymia
Chronic mood disturbance, at least 1 year, 2/5 criteria while depressed
Poor appetite/overating, sleep change, diminished energy, difficulty concentrating, hopeless feeling
Substance Abuse
Epi-90% HS students try etoh, 50% illegal drug, 60% cigs, based on friends/fam/actingout, social.
Dx substance abuse if mood/sleep disturb, truancy, decline in school, change in relationships, wl, app change, depression, etc
Alcohol
Problem drinking = being drunk 6+ times in a year, problem in areas w/ driking- driving, argumentsin class Binge drinking- 5+ nights drinking, fight, drive drunk, sex Alcoholism = preoccupation with/impaired control over drinking CAGE = felt need to cut down? annoyed by criticms of drinking? guilty? eye opener?
Tobacco
Smoke? more likely to try other drugs, do worse in school, very addictive
Risk of CAD, stroke, cancers, CLD, asthma, ulcers, prego issues, 3 mil teens chew!
Marijuana
Most widely used illicit drug- tachy, mydriasis, sleepiness, red eyes, dry mouth, hallucinations (aud/vis), increased appetite, impaired cognition.
Long term conseq = asthma, impaired memory/learning, truancy, less interactions, depression
Obesity
20% over ideal body weight, BMI >95% for age/sex, body fat measure skin fold thickness at triceps/subscap, BMI>95% for age/sex
Why? genetic, calories, energy, underlying is only 5%(hypothy, cushin, praderwilli)
Effects- earlier puberty, htn, cvd, chol/trig, t2dm, gallbladder, ortho, poor image, depression
MGMT- tx challenging/multifaceted, promote behavior change, balance weight reduction
Arex/Bulimia
Epi- Arex .5-1% , bulimia 1-5%
Dx- arex- calories insufficient, delusion of fat/obsession to be thing. Specific- refusal to maintian body weight, 15% below idea, intense fear of weight gain, disturbed BI, absence of 3 menses, excessive exercise, emotion waves, withdrawal peer/sfam, preoccupy w/ food
Dx- bulimia- binging, at least 2x week/3 months, lack of control, anxiety/guilt/sadness after, purging, fasting/rig exercise/diet pills, distrubed body image
MGMT- involve family, normal nutrtion established, hospitalization if severe complications or outpt failure
AN labs/exams
Weight > 15% below level, hypotherm, hypotn, brady, delayed growth, malnourished, dehydrated,
anemia, leukopenia, low thyroxine, low gluc, low ca, low mag, low phosph, low sex, high BUN, high LFTs
BN labs/exams
less ill-apperaing, normal weight, hypother/hypotn/brady if excessive purging, vom sequelae (trauma to palate/hands, loss of dental enamel, parotid swell)
low CL, low k+, high BUN if excessive vom
Pregnancy
1 mil teen pregos every year, 1/5 pregnancies occur in first month after sex, 80% unintentional, 1/2 result in delivery, 1/3 abort, 1/6 miscarriage
High-risk prego, up incidence of helath probls, LBW, higher mortality, maternal anemia HTN PTL, dropping out of school, unemployment/need for assistance
Contraception
1/2 kids don’t use anything-ignorance, denial, barriers to getting it, refual, religious believes, sorta want prego
Methods = abstinence, condom, female condom, vag diaphragm (can put in up to 6 hours before but risk of uti/awk), cervical cap (keep in 48 hours, but need paps more), IUD great!, OCP- hard to remember, no take if prego, breast/endo cancer, stroke, CAD, liver (sorta ci with migraines, htn, h/a, diabetes, sickle cell, lipids, smoke), depot
Vaginitis
T. vag- yellow-green, smelly, strawberry cervix, inflamm, dyspar, or asx, dx w/ wet mount, + culter, vag ph >4.5, take metro
BV- most common, fishy, graw white thing discharge, whiff test, clue cells, ph> 4.5, tx metro
Candida- severe itch, white curdy, clin sx, fungal hyphae, normal pH, yeast! KOH microscopy
Cervicitis
C. trachoma- pussy d/c, friable/red cervix, dysuria/frequency, 75% asx, culture gold standard, non/culture NAAT/immuno, PCR, complex - PID, TOA, fitz-hugh curtis, neonatal conjunctivits, pneumo, mgm w/ oral doxy, erythro, azithro
Gonorrhea- mucopurulent discharge, vag bleeding ? dysuria, frequency, dyspar, common asx in females, culture, gstain neg diplococci, non culture, same complications + asymmetric polyarthritis, pap/pustular lesions, mengingitis/endocarditis, septic. IM ceftriaxone, ofloxacin, cefixime, cirpoflox
PID
Polymicro, maybe gon/chlamydia, more common infirst half menstrual cycle (yeeks!),
Dx- need lower ab, uterine/cerv motion tender, unilat bilat adnexal, and one of following- fever, wbc>10.5, elevated ESR/CRP, lab evidence gono/trach
MGMT- hospitalize if mass, uncertainty, prego, failed, inpt w/ IV cefoxitin + oral doxy or IV clinda + IV genta
Outpt- 14 day oflox/clinda or single dose IM cef + 14 doxy
Urethritis
More common in males, in women typically cervicitis too
usually gono or non gonno, can be HSV<ureaplasma, mycoplasma, or t. vag
findings- dysuria, increased frequency, mucopus d/c, asx
Dx- with d/c, +5 wbc/field on d/c, 10+ on urine, positive leukocyte esterase
Def dx- swab urethra, or d/c
MGMT- tx same as for gon/chlamyd
Genital ulcers
Usually hsv1/2, syphilis or chancroid
Warts (genital)
most common STD< cased by HPV, direct contact, HPV 16/18 cervical carcinoma but no warts, external warts = condlomata acuminaa
itching, pain, dyspareunia, maybe external, maybe asx…mgmt annoying, topical podophyllin, tca, cryo, surgical/laster
Diff dx
HSV1/2 = painful, shallow, culture with positize tzanck, hsv culture,
Primary syphilis- well demarcated, inguinal adeno, IM penicilli
Chancroid- red irregular border, purulent, haemophilus ducreyi, z-pack/eryhtro
Menstrual issues
Follicular = 7-22 days, begins with pulsatile GnRH, LH /FSH mature ovarian follicles, estradiol,ovulation after surge, luteal = progresterone
Dysmennorhea
most common, pain, primary = just general, secondary = pelvic abnormal, too much prostaglandin, pain spasms, n/v, diarrhea. NSAIDS/ocp
Primary amenn w/ normal genitalia/pubertal delay
Turner (high fsh/lh), ovarian fail (high), hypothalamic (low fsh)
Primary amenn w/ no uterus, normal puberty
Testic feminization 46 Xy, defect in andorgen receptor => inability to respond to testosterone, blind pouhc vagina, low fsh/lh.
MRKH- 46 XX, mullerian issue, ormal levels
Primary/secondary w/ normal errythang
hypothalamic supp- low fsh/lh PCOS=high lh and high lh/fsh pit infarct- low prolactin - low fsh/lh, high prolactin Outflow obstruction, normal POF, endocrine- high fsh/lh
Amenn
primary if age 16 and nada, or 14 w/ no sex char, 2ndary if later
Do prego test, tsh,thyroxine, fasting prolactin, FSH/LH levels
Abnormal bleeding
DUB = 90% of stuff..polymenn too often, menorrhagia too much, metror irregular, oligo regular intervals but more than 35 days apart
Aovulation- endometrium too thick, bleeding spontaneously, or infections, prego, blood dyscrasia, cervica/vag polyps, uterine abnormal, meds, foreign bodies, trauma/assault, do hx, physical, lab test,
hormones if any anemia at all (ocp or progestin only), iron, and d&c if hormones fail
Gynecomastia
60% male adolescents, etio unknown, maybe peripheral conversion, look at meds, testicular tumors, thyroid/liver disease potential
Lab studies not needed if normal growth, manage w/ reassurance, resolves in a year
Painful scrotal mass
Torsion of spermatic cord = most serious/acute, sudden onset pain and n/v, swollen tender testicl/edema, no cremasteric reflex, pain relief when elevated
Dx w/ h/p, can tdo a techtenituim scan or doppler (absent pulsations)
tx- surgical detorsion and fix both testes, urologic emergency
Torsion of testicular appendage
Gradual onset, testic/inguinal/suprapubic, blue dot sign on scrotum- cyanotic appendage. Doppler will be normal, rest/analgesia, resolves on it’s own
Epidimytis
Infec/inflamm epidiymis, from gonorrhea/chlamydia
Acute onset pain/swelling w/ frequency, dysria/d/c
Swollen tender epididymis
Dx w/ ua wbcs, doppler w/ increased flow/scan w/ uptake up, manage like cervicits + bed rest
Painless scrotal mass
Testicular neoplasm, most common SOLID tumor from germ cells. Cryptorchidism = testes failing to descent, higher malig risk
Firm/irreg painless nodule, solid mass on transillumination
Doppler the scrotum, look for HCG and AFT, MGMT = surgery/rads/chemo
Indirect inguinal hernia
Processus vag fails to obliterate, pianless inguinl swelling, dx on h/p, elective repair, or emergent
Hydrocele
Collection of fluid in tunica, transillum, painless soft cystic, reassure
Varicocele
dilation/tortuos veins, most often LEFT half, bag of worms, valsalva, dx on h/p, if painful or w/ small testicle, urology referral
