Adolescents

Question 1

Danger Signals! Acetaminophen Poisoning + Staging

Answer 1

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

Question 2

Danger Signals! Testicular Torsion

Answer 2

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!

Question 3

Danger Signals! Testicular Cancer

Answer 3

• 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

Question 4

Danger Signals! Hodgkin’s Lymphoma

Answer 4

• 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

Question 5

Pel-Ebstein sign

Answer 5

enlarged and painless cervical, axillary, groin, and supraclavicular lymphadenopathy associated w/ fever (Pel-Ebstein sign) +
- fatigue
- unexplained weight loss
- night sweats

Question 6

Normal Findings: Adolescence (defined)

Answer 6

onset of puberty until sexual maturity

Question 7

Top 3 causes of death (15-19 years)

Answer 7

1. Accidents (e.g., MVA)
2. Suicide (e.g., intentional suffocation)
3. Homicide (e.g., intentional firearm use)

Question 8

Normal Findings: Puberty (defined)

Answer 8

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

Question 9

Puberty: Girls - Precocious vs delayed

Answer 9

Precocious puberty if puberty starts before 8 years

Delayed if no breast development (Tanner stage II) by 12 years

Question 10

Puberty: Girls - Growth Spurt

Answer 10

• 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

Question 11

Puberty: Girls - Pubertal Timeline

Answer 11

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

Question 12

Puberty: Girls - Mittelschmerz

Answer 12

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

Question 13

Puberty: Girls - Menarche

Answer 13

• 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

Question 14

Puberty: Girls - Menstrual Cycle

Answer 14

• 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)

Question 15

Puberty: Girls - Dysmenorrhea

Answer 15

• 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)

Question 16

Puberty: Boys - Precocious ve delayed

Answer 16

Precocious puberty if starts before 9 years

Delayed if no testicular enlargement by age 14

Question 17

Puberty: Boys - Growth Spurt

Answer 17

• approx 2 years later than girls’ (age 11-15 years)

Question 18

Puberty: Boys - Spermarche

Answer 18

• average age is 13.3 years

Question 19

Tanner Stages: Boys

Answer 19

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)

Question 20

Tanner Stages: Girls

Answer 20

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)

Question 21

Pubic Hair (both genders)

Answer 21

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

Question 22

Immunization Schedule for Adolescents (ages 11-18): Tdap

Answer 22

Boostrix, Adacel
- All 11-12 years → Give Tdap as booster and Td Q10 years for lifetime

Question 23

Immunization Schedule for Adolescents (ages 11-18): HPV

Answer 23

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

Question 24

Immunization Schedule for Adolescents (ages 11-18): Meningococcal (ACQWY-D [Menactra], MenACWY-CRM [Menveo], MenB-4C [Bexsero], MenB-FHbp [Trumenba])

Answer 24

• 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)

Question 25

Immunization Schedule for Adolescents (ages 11-18): Influenza Inactivateds

Answer 25

Vaccinate everyone from age 6 months and older annually

Question 26

Immunization Schedule for Adolescents (ages 11-18): Hepatitis B

Answer 26

Recombivax HB)
- Catch-up: Give remaining doses if not completed

Question 27

Immunization Schedule for Adolescents (ages 11-18): Hepatitis A

Answer 27

HAVRIX, VAQTA
- Catch-up: give 2nd dose if not completed
- Recommended for children w/ certain health/lifestyle conditions placing them at risk

Question 28

Immunization Schedule for Adolescents (ages 11-18): MMR`

Answer 28

Catch-up: Give 2nd dose if not completed

Question 29

Immunization Schedule for Adolescents (ages 11-18): Varicella

Answer 29

• If no reliable hx of chickenpox (verbal okay)
• live virus precautions

Question 30

Vaccine Adverse Event Reporting System (VAERS)

Answer 30

government program to report clinically adverse events

Question 31

Lab tests: Elevated Alkaline Phosphatase

Answer 31

• children and adolescents normally have higher blood levels compared w/ adult d/t growing bone
• produced by osteoblasts

Question 32

Legal Issues: Right to Consent and Confidentiality

Answer 32

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])

Question 33

Legal Issues: Emancipated Minor Criteria

Answer 33

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

Question 34

Legal Issues: Confidentiality

Answer 34

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)

Question 35

Health Promotion: High-risk behaviors for screening

Answer 35

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)

Question 36

Delayed Puberty
1. Definition/Etiology
2. Labs

Answer 36

1. • 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)
2. • 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)

• 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

Question 37

Primary and Secondary Amenorrhea (defined)
1. Definition/Etiology
2. Labs
3. Treatment Plans
4. Complications

Answer 37

1. 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

2. • 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
3. • Educate about ↑ caloric intake and ↓ exercise
     - Prescribed calcium w/ Vit D 1,200-1,500 mg daily and vit E 400 IU daily
4. • 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

Question 38

Anorexia Nervosa
1. Definition/Etiology
2. Clinical Findings/Clinical Presentation

Answer 38

1. • usually onset is during adolescence
     - involves an irrational preoccupation w/ and intense fear of gaining weight

2 types:
- patient engages in restriction (dieting, excessive exercise)
- binge eating and purging
Ex of purging → excessive use of laxatives, enemas, diuretics, and vomiting

2. • 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

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

Question 39

Gynecomastia
1. Definition/Etiology
2. Clinical Presentation
3. Objective Findings
4. Treatment Plan

Answer 39

1. • 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
2. • 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
3. • 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
4. • 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

Question 40

Pseudogynecomastia
1. Definition/Etiology
2. Labs

Answer 40

1. • 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
2. None. Diagnosed by clinical presentation

Question 41

Adolescent Idiopathic Scoliosis
1. Definition/Etiology
2. Clinical Presentation
3. Screening Test
4. Treatment Parameters
5. Management

Answer 41

1. • 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)
2. • painless and asymptomatic
     - may c/o that one hip, shoulder, breast, or scapula is higher than the other
     - no complaints of pain
3. • 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
4. • 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
5. • 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!

** Scoliosis treatment needed for a ≥20º curve; for curves <20 º, observe for worsening

Question 42

Osgood-Schlatter Disease
1. Definition/Etiology
2. Clinical Presentation
3. Diagnostics/Treatment Plan

Answer 42

1. • 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
2. • 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
3. • 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

Question 43

Klinefelter Syndrome
1. Definition/Etiology
2. Clinical Presentation
3. Labs
4. Diagnostics/Treamtent Plan

Answer 43

1. 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)\
2. • 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)

3/4. Treatment includes testosterone replacement and fertility treatment

Question 44

Turner’s Syndrome
1. Definition/Etiology
2. Clinical Presentation

Answer 44

1. 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
2. • 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])