Adolescents Flashcards
Danger Signals! Acetaminophen Poisoning + Staging
Intentional Ingestion
- Acetaminophen damages liver → mild-severe fulminant liver failure
- AKA paracetamol and sold as Tylenol and others
Stage 1 (up to 24 hours after overdose)
- pt usually asymptomatic but may have N/V and w/ very large doses, lethargy and malaise
Stage II (18-72 hrs after overdose)
- Pt c/o RUQ pain w/ abdominal pain, N/V, and ↑ LEFTs, prothrombin time and bilirubin concentrations
- possible nephrotoxicity (↑ BUN, creatinine)
Stage III (72-96 hrs after overdose)
- hepatic necrosis present as jaundice, clotting ds, hypoglycemia, and hepatic encephalopathy
- AKI w/ oliguria may develop
- m ost deaths from organ failure occur within 72-96 hrs
With acute overdose, serum acetaminophen concentration should be measured ASAP, but at least 4 hours must have passed since ingestion to obtain accurate blood level (if <4 hrs, blood level is not accurate)
Antidote: N-acetylcysteine given IV
Danger Signals! Testicular Torsion
Acute Scrotum
- pubertal male awakens w/ abrupt onset of unilateral testicular pain, increases in severity
- pain may radiate to lower abdomen and/or groin
- ~90% of patients have N/V
Ischemic changes → severe scrotal edema, redness, and testicular pain
- Ipsilateral (same side) cremasteric reflex is absent
- testicle may be noted to be high riding w/ a transverse lie
Highest incidence is during adolescence
- May be confused w/ torsion of appendix testis (more common in prepubertal boys, less N/V, “blue dot sign”)
- UA is neg for puria and bacteruria
- Doppler US is initial diagnostic test
- Testicle is not functional after 24 hrs if not repaired
→ Refer to ED! Surgical emergency!
Danger Signals! Testicular Cancer
- teenage-to-adult male c/o “heaviness” in scrotum or hardened mass that is usually painless
- some pt may have testicular discomfort or numbness but not pain
- affected testicle has a firm texture
- more common in males 15-35 years
- Cryptorchidism is a strong risk factor
Danger Signals! Hodgkin’s Lymphoma
- Pt presents w/ enlarged and painless cervical, axillary, groin, and supraclavicular lymphadenopathy associated w/ fever (Pel-Ebstein sign) +
- fatigue
- unexplained weight loss
- night sweats
- may report having severe pain on or over malignant areas a few mins after drinking alcohol
** most common CA in teenagers 15-19 years are Hodgkin’s lymphoma (16%) and germ cell tumors (16%) such as testicular and ovarian cancer
** Hodgkin’s lymphoma presents as enlarged lymph nodes w/ fever, night sweats, and pain (lymph nodes) after drinking alcohol
Pel-Ebstein sign
enlarged and painless cervical, axillary, groin, and supraclavicular lymphadenopathy associated w/ fever (Pel-Ebstein sign) +
- fatigue
- unexplained weight loss
- night sweats
Normal Findings: Adolescence (defined)
onset of puberty until sexual maturity
Top 3 causes of death (15-19 years)
- Accidents (e.g., MVA)
- Suicide (e.g., intentional suffocation)
- Homicide (e.g., intentional firearm use)
Normal Findings: Puberty (defined)
period in life when secondary sexual characteristics start to develop because of hormonal stimulation
Girls’ ovaries start producing estrogen and progesterone
Boys’ testes start producing tesosterone
All these changes → reproductive capability
Puberty: Girls - Precocious vs delayed
Precocious puberty if puberty starts before 8 years
Delayed if no breast development (Tanner stage II) by 12 years
Puberty: Girls - Growth Spurt
- majority of physical changes occur b/w ages 10-13 years
- majority of skeletal growth occurs before menarche; afterward, growth slows down
- girls start their growth spurts approx 2 years earlier than boys
Puberty: Girls - Pubertal Timeline
Breast development → peak growth acceleration → menarche
- most of a girl’s height is gained before menarche
- skeletal growth sin girls is considered complete within 2years after menarche
Puberty: Girls - Mittelschmerz
Ovulation Pain
- unilateral midcycle (about 14 days before the next period) pelvic pain that is caused by an enlarging ovarian follicle or the rupture of the follicle at the time of ovulation
- pain may last a few hours to a few days
- may occur intermittently
Puberty: Girls - Menarche
- Avg age is ~122 years (12.34 years) in US (range 8-15 years)
- First 1-2 years after onset of menarche, common to have irregular periods because of irregular ovulation (may skip a month or longer intervals, lighter bleeding)
- after Tanner stage II starts (breast bud stage), girls start menses within 2 years
- delayed puberty is determined if no breast development by age 13 or menarche does not begin by 15 years
Puberty: Girls - Menstrual Cycle
- average duration: 28 days
- in younger teens, cycles range from 21-45 days
- in adults, they can range from 21-35 days
- avg duration of menstrual bleeding is ~3-5 days (range 2-7 days)
- Day 1 of menstrual cycle start as spotting; then blood flow becomes heavier for 2-3 days, then bleeding lightens until it stops
- most fertile period in the cycle is ~3 days before and during ovulation (days 11-14)
Puberty: Girls - Dysmenorrhea
- painful periods are d/t severe menstrual cramps caused by high levels of prostaglandins
- Tx is use of heating pads and NSAIDs such as ibuprofen (Advil, Motrin) and naproxen (Aleve)
Puberty: Boys - Precocious ve delayed
Precocious puberty if starts before 9 years
Delayed if no testicular enlargement by age 14
Puberty: Boys - Growth Spurt
- approx 2 years later than girls’ (age 11-15 years)
Puberty: Boys - Spermarche
- average age is 13.3 years
Tanner Stages: Boys
Stage I - prepuberty
II - Testes begin to enlarge, w/ increased rugation of scrotum
III - penis elongates; testicular/scrotal growth continues; scrotal color starts to darken
IV - penis thicken sand ↑ in length; testes are larger and scrotal skin darkens
V - adult pattern
- Puberty starts at Tanner stage II in girls or boys; puberty ends at Tanner stage V; know these stages (II-V)
Tanner Stages: Girls
Stage I - Prepuberty
II - Breast bud (onset of thelarche, or breast development)
III - Breast tissue and areola are in one mount
IV - Areola/nipples separate and form a secondary mount
V - Adult pattern
- Puberty starts at Tanner stage II in girls or boys; puberty ends at Tanner stage V; know these stages (II-V)
Pubic Hair (both genders)
Stage I - Prepuberty
II - Sparse growth of straight hair, easily counted
III - Hair is darker and starts to curl
IV - hair is curly but not on medial thigh yet as in adult; hair is coarser
V - Adulit pattern; hair spreads to medial thigh and lower abdomen
Immunization Schedule for Adolescents (ages 11-18): Tdap
Boostrix, Adacel
- All 11-12 years → Give Tdap as booster and Td Q10 years for lifetime
Immunization Schedule for Adolescents (ages 11-18): HPV
Gardasil
- All 11-12 year old → give to girls and boys
- Minimum age: 9 years
- All 11-12 years → Give 1st shot, needs 2 doses, 6-12 months apart
- Age 15026 years: need 3 dosease
Immunization Schedule for Adolescents (ages 11-18): Meningococcal (ACQWY-D [Menactra], MenACWY-CRM [Menveo], MenB-4C [Bexsero], MenB-FHbp [Trumenba])
- All 11-12 years → give single dose of Menactra or Menveo vaccine, w/ booster at age 16
- Catch-up: Age 13-18 years, give Menactra or Menveo; if 1st dose at age 13-15 years, need booster at age 16-18; if first dose at age 16 years, no booster dose is needed
- Clinical discretion: young adults 16-23 years may be vaccinated w/ either Bexsero or Trumenba
** Meningococcal vaccine is recommended for all, starting at 11-12 years (not just for college freshmen living in dormitories)
Immunization Schedule for Adolescents (ages 11-18): Influenza Inactivateds
Vaccinate everyone from age 6 months and older annually
Immunization Schedule for Adolescents (ages 11-18): Hepatitis B
Recombivax HB)
- Catch-up: Give remaining doses if not completed
Immunization Schedule for Adolescents (ages 11-18): Hepatitis A
HAVRIX, VAQTA
- Catch-up: give 2nd dose if not completed
- Recommended for children w/ certain health/lifestyle conditions placing them at risk
Immunization Schedule for Adolescents (ages 11-18): MMR`
Catch-up: Give 2nd dose if not completed
Immunization Schedule for Adolescents (ages 11-18): Varicella
- If no reliable hx of chickenpox (verbal okay)
- live virus precautions
Vaccine Adverse Event Reporting System (VAERS)
government program to report clinically adverse events
Lab tests: Elevated Alkaline Phosphatase
- children and adolescents normally have higher blood levels compared w/ adult d/t growing bone
- produced by osteoblasts
Legal Issues: Right to Consent and Confidentiality
No parental (or guardian) consent is necessary for the following:
- Contraception
- Treatment for STDs
- Diagnosis and management of pregnancy
** No parental consent is needed for health services r/t sexual activity (STD testing, pregnancy tests, birth control prescriptions)
* If not related to sexual activity, then need parental consent (dysmenorrhea, headache, upper respiratory infection [URI])
Legal Issues: Emancipated Minor Criteria
These minors may give full consent as an adult without parental involvement
- Legally married
- active duty in armed forces
** Memorize criteria for an emancipated minor
- Do NOT confuse right to confidentiality w/ emancipated minor status
Legal Issues: Confidentiality
Confidentiality can be broke in the following situations:
- Gunshot wounds and stab wounds, which must be reported to the police (regardless of victim’s age)
- Child abuse (actual or suspected abuse), which must be reported to the authorities
- Suicidal ideation and/or attempt (discharge to parents/guardians or hospital)
- Homicidal ideation or intent (esp mental health providers)
Health Promotion: High-risk behaviors for screening
Adolescent health history is obtained from both parent and child initially; then the adolescent is interviewe4d alone w/out parent
During physical exam or wellness visit, assess teenager for high-risk behaviors
- Intensive behavior counseling is recommended
Following are high-risk behaviors to screen for:
- Sexual activity → use of condoms, birth control, intimate partner violence (e.g., rape), s/sx of STDs
- Safety → driver safety (seatbelt/helmet use); assess to guns/gun safety; smoking, alcohol, and drug use
- Mental health → s/sx of depression and antisocial behaviors (e.g., gangs)
Delayed Puberty
1. Definition/Etiology
2. Labs
- absence of secondary sexual characteristics by age of 13 for girls (such as breast bud) or at the age of 14 for boys
- child remains in Tanner stage I (prepubertal)
- absence of secondary sexual characteristics by age of 13 for girls (such as breast bud) or at the age of 14 for boys
- Serum pregnancy test
- Check prolactin level; if prolactin level is ↑, next step is to order CDT scan of sella turcica (location of pituitary gland inside skull)
- Serum pregnancy test
- For primary amenorrhea 9no menses by age 15), R/O hypogonadism by checking hormone levels (e.g., FSH, LH, TSH)
- R/O chromosomal disorders, absence of uterus/vagina, and imperforate hymen
- X-ray of the hand is used for estimating “bone age”
→ when long-bone epiphyses (growth plates) are fused, skeletal growth is finished
→ Refer to pediatric endocrinologist if no growth spurt, delayed puberty, others
Primary and Secondary Amenorrhea (defined)
1. Definition/Etiology
2. Labs
3. Treatment Plans
4. Complications
- Primary amenorrhea → No menarche by age 15 year sin presence of normal growth and secondary sex characteristics
- nearly half of cases are caused by chromosomal disorders (43%) such as Turner syndrome
Secondary amenorrhea → no menses for > 3 cycles or 6 months if previously had menses
- most common cause is pregnancy
- others are ovarian disorders, stress, anorexia, and PCOS
Secondary Amenorrhea associated w/ Exercise and Underweight
- excessive exercise and/or sports participation has a higher incidence of amenorrhea (and infertility) because of relative caloric deficiency
- “Female athlete triad” → anorexia nervosa/restrictive eating, amenorrhea, and osteoporosis
- Pregnancy test (serum human chorionic gonadotropin [HCG])
- serum prolactin level (R/O prolactinoma-induced amenorrhea)
- serum TSH; also FSH and LH (R/O premature ovarian failure)
- If amenorrhea for >6 months, measure bone density
- Pregnancy test (serum human chorionic gonadotropin [HCG])
- Educate about ↑ caloric intake and ↓ exercise
- Prescribed calcium w/ Vit D 1,200-1,500 mg daily and vit E 400 IU daily
- Educate about ↑ caloric intake and ↓ exercise
- Osteopenia/osteoporosis (stress fractures)
- Myocardial atrophy, arrhythmia (sudden death), bradycardia, hypotension
- Hypoglycemia, dehydration, electrolytes
- Lanugo (fine, downy hair), telogen effluvium (hair loss), xerosis (dry skin), infertility
- Low BMI, cachexia, anemia, respiratory failure
- Osteopenia/osteoporosis (stress fractures)
Anorexia Nervosa
1. Definition/Etiology
2. Clinical Findings/Clinical Presentation
- usually onset is during adolescence
- involves an irrational preoccupation w/ and intense fear of gaining weight
- usually onset is during adolescence
2 types:
- patient engages in restriction (dieting, excessive exercise)
- binge eating and purging
Ex of purging → excessive use of laxatives, enemas, diuretics, and vomiting
- Marked weight loss (BMI ≤18.5), bradycardia (40-49 bpm), VS unstable, hypotension
- Lanugo (↑ lanugo, esp in face, back, and shoulders)
- Osteoporosis or osteopenia
- Swollen feet (low albumin), dizziness, abdominal bloating
- Marked weight loss (BMI ≤18.5), bradycardia (40-49 bpm), VS unstable, hypotension
Exam tip* recognize how anorexia pts present (e.g., lanugo, peripheral edema, amenorrhea, significant weight loss >10% of body weight)
- ↑ risk of osteoporosis or osteopenia → For birth control, avoid Depo Provera and other progesterone-only contraceptives because they can cause bone loss
- Low albumin level results in peripheral edema
Gynecomastia
1. Definition/Etiology
2. Clinical Presentation
3. Objective Findings
4. Treatment Plan
- Excessive growth of breast tissue in males
- can involve 1-2 breasts
- physiologic gynecomastia is benign
- more common during infancy and adolescence
- normal in up to 40% of pubertal boys (peaks at 14 years)
- most cases resolve spontaneously within 6 months-2 years
- Excessive growth of breast tissue in males
- gradual onset of enlarged breasts
- or asymmetrical breast tissue (one may be larger)
- child is embarrassed and scared about breast changes
- affected breast may be tender to palpation
- gradual onset of enlarged breasts
- Round, rubbery, and mobile mound (dislike) under areola of both breasts
- skin has no dimpling, redness, or changes
- if mass is irregular, fixed, or hard, or rapid growth in breast size or if suspect secondary cause → refer to specialist
- Round, rubbery, and mobile mound (dislike) under areola of both breasts
- Evaluate for Tanner stage (check testicular size, pubic hair, axillary hair, body odor)
- Check for drug use: Both illicit and prescription (e.g., steroids, cimetidine, antipsychotics)
- R/O serious etiology (e.g., testicular or adrenal tumors, brain tumor, hypogonadism)
- Recheck patient in 6 months to monitor for changes
- Evaluate for Tanner stage (check testicular size, pubic hair, axillary hair, body odor)
Pseudogynecomastia
1. Definition/Etiology
2. Labs
- bilateral enlarged breast is d/t fatty tissue (adipose tissue)
- common in obese boys and men
- both breasts feel soft to touch and are not tender
- no breast bud or disklike breast tissue is palpable
- bilateral enlarged breast is d/t fatty tissue (adipose tissue)
- None. Diagnosed by clinical presentation
Adolescent Idiopathic Scoliosis
1. Definition/Etiology
2. Clinical Presentation
3. Screening Test
4. Treatment Parameters
5. Management
- Lateral curvature of the spine that may be accompanied by spinal rotation
- more common in girls (80%)
- Scoliosis will most likely worsen (66% of cases) if it starts in beginning of the growth spurt
- Rapid worsening of curvature is indicative of secondary causes (e.g., Marfan or Ehlers-Danlos syndrome, cerebral palsy, myelomeningocele)
- Lateral curvature of the spine that may be accompanied by spinal rotation
- painless and asymptomatic
- may c/o that one hip, shoulder, breast, or scapula is higher than the other
- no complaints of pain
- painless and asymptomatic
- Adam’s Forward Bend Test
- Bend forward w/ both arms hanging free
- look for asymmetry of spine, scapula, thoracic, and lumbar curvature
- check height
- measure the Cobb angle (degree of spinal curvature)
- full spine x-rays are used to measure degree or curvature
- Adam’s Forward Bend Test
- Curves <20º → observe and monitor for changes in spinal curvature
- Curves of 20-40º → bracing (e.g., Milwaukee brace)
- Curves of >40º → Surgical correction w/ Harrington rod used on spine and other options
- Curves <20º → observe and monitor for changes in spinal curvature
- Check Tanner stage (Tanner stages II-V)
- Order spinal x-ray (posteroanterior [PA] view) to measure Cobb angle
- Refer ALL patients w/ scoliosis to a pediatric orthopedic specialist!
- Check Tanner stage (Tanner stages II-V)
** Scoliosis treatment needed for a ≥20º curve; for curves <20 º, observe for worsening
Osgood-Schlatter Disease
1. Definition/Etiology
2. Clinical Presentation
3. Diagnostics/Treatment Plan
- common cause of knee pain in young athletes
- caused by overuse of knee
- repetitive stress on patellar tendon by quadriceps muscles causes pain, tenderness,and swelling at tendon’s insertion site (tibial tuberosity)
- usually affects one knee but can be bilateral
- most common during rapid growth spurts in teenage males who are physically active and/or play sports that stress the patellar tendon (e.g., basketball, soccer, running)
- condition abates when growth stops
- common cause of knee pain in young athletes
- teen undergoing rapid growth spurt c/o tender bony mass over anterior tubercle of one knee
- pain is worsened by some activities (squatting, kneeling, jumping, climbing up stairs)
- knee pain improves w/ rest and avoidance of aggravating activity
- reports presence of bony mass on anterior tibial tubercle; slightly tender
- almost all causes resolve spontaneously within a few weeks to months
- R/O avulsion fracture (tibial tubercle) if acute onset of pain posttrauma → order lateral x-ray of knees
- teen undergoing rapid growth spurt c/o tender bony mass over anterior tubercle of one knee
- RICE (Rest affected knee; use ice pack 3x daily
- avoid aggravating activities/sports that typically reduce or resolve pain
- may continue to play based on degree of pain after sports participation
- play doe snot necessarily worsen condition
- use acetaminophen (Tylenol) or NSAIDs for pain PRN
- Quadriceps strengthening and quadriceps/hamstring stretching exercises aimed at stabilizing knee joint may also be beneficial
- RICE (Rest affected knee; use ice pack 3x daily
Klinefelter Syndrome
1. Definition/Etiology
2. Clinical Presentation
3. Labs
4. Diagnostics/Treamtent Plan
- condition in which males are born w/ extra X chromosome (e.g., 47, XXY)
- condition occurs approx in 1/1,000 live births
- one of the causes of primary hypogonadism (deficiency in testosterone)\ - testicles are small and firm w/ small penis
- tall stature, wider hips, and reduced facial/body ahir, higher risk of osteoporosis (compared w/ normal males)
- testicles are small and firm w/ small penis
3/4. Treatment includes testosterone replacement and fertility treatment
Turner’s Syndrome
1. Definition/Etiology
2. Clinical Presentation
- females w/ complete or partial absence of second sex chromosome (45, X);
- occurs in approx 1/2,5000 live-born females
- congenital lymphedema of hands and feed, webbed neck, high-arched palate, and short fourth metacarpal - short stature (height usually below 50th percentile)
- Ovarian failure, cardiovascular and renal issue sor ear malformations and other health problems (as well as amenorrhea d/t premature ovarian failure [infertility])
- short stature (height usually below 50th percentile)
