Adolescents

Question 1

Acetaminophen Poisoning (Intentional Ingestion)

Answer 1

Acetaminophen damages the liver, resulting in mild-to-severe fulminant liver failure.
Acetaminophen is also known as paracetamol and sold as Tylenol and others.

Stage 1 (up to 24 hours after overdose): Patients are usually asymptomatic but may have nausea and vomiting and, with very large doses, lethargy and malaise.

Stage II (18–72 hours after overdose): Patients complain of right upper quadrant pain with abdominal pain, nausea, and vomiting; elevated liver function tests (LFTs), prothrombin time, and bilirubin concentrations; possible nephrotoxicity (elevated blood urea nitrogen [BUN], creatinine).

Stage III (72–96 hours after overdose): Hepatic necrosis presents as jaundice, clotting disorders, hypoglycemia, and hepatic encephalopathy. Acute kidney injury with oliguria may develop. Most deaths from organ failure occur within 72 to 96 hours.

Stage IV (4 days–3 weeks after overdose): If patient survives, symptoms and signs of organ failure resolve.

With acute overdose, serum acetaminophen concentration should be measured as soon as possible, but at least 4 hours must have passed since ingestion to obtain accurate blood level (if <4 hours, blood level is not accurate).

Antidote is N-acetylcysteine given intravenously.

Question 2

Testicular Torsion (Acute Scrotum)

Answer 2

Pubertal male awakens with abrupt onset of unilateral testicular pain that increases in severity.

Pain may radiate to the lower abdomen and/or groin.

Almost all patients (90%) also have nausea and vomiting.

Ischemic changes result in severe scrotal edema, redness, and testicular pain.

Ipsilateral (same side) cremasteric reflex is absent, and the testicle may be noted to be high riding with a transverse lie.

Highest incidence is during adolescence.

May be confused with torsion of appendix testis (more common in prepubertal boys, less nausea/vomiting, “blue dot sign”).

Urinalysis (UA) is negative for pyuria and bacteriuria.

Doppler ultrasound is the initial diagnostic test.

Testicle is not functional after 24 hours if not repaired. Refer to ED.

This is a surgical emergency.

Question 3

Testicular Cancer

Answer 3

Teenage-to-adult male complains of a “heaviness” in scrotum or a hardened mass that is usually painless.

Some patients may have testicular discomfort or numbness, but not pain.

The affected testicle has a firm texture.

More common in males from the age of 15 to 35 years.

Cryptorchidism is a strong risk factor

Question 4

Hodgkin’s Lymphoma

Answer 4

Patient presents with enlarged and painless cervical, axillary, groin, or supraclavicular lymphadenopathy associated with fever (Pel-Ebstein sign), fatigue, unexplained weight loss, and night sweats.

May report having severe pain on or over malignant areas a few minutes after drinking alcohol.

The most common cancers in teens aged 15 to 19 years are Hodgkin’s lymphoma (16%) and germ cell tumors (16%) such as testicular and ovarian cancer.

Question 5

Girls; puberty

Answer 5

Precocious puberty if puberty starts before age 8 years

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

Question 6

Boys; Puberty

Answer 6

Precocious puberty if starts before age 9 years

Delayed puberty if no testicular enlargement by age 14 years

Question 7

Tanner stages

Answer 7

Boys

Stage II: Testes begin to enlarge, with increased rugation of scrotum

Stage III: Penis elongates; testicular/scrotal growth continues; scrotal color starts to darken

Stage IV: Penis thickens and increases in length; testes are larger and scrotal skin darkens

Girls

Stage II: Breast bud (onset of thelarche, or breast development)

Stage III: Breast tissue and areola are in one mound

Stage IV: Areola/nipples separate and form a secondary mound

Question 8

Meningococcal vaccine is recommended for

Answer 8

all, starting at age 11 to 12 years (not just for college freshmen living in dormitories).

Question 9

CDC recommends HPV vaccine for

Answer 9

both females and males until age 26 years.

Question 10

Antidote of acetaminophen poisoning is

Answer 10

intravenous (IV) N-acetylcysteine.

Question 11

Hodgkin’s lymphoma presents as

Answer 11

enlarged lymph nodes with fever, night sweats, and pain (lymph nodes) after drinking alcohol.

Question 12

Vaccine Adverse Event Reporting System (VAERS):

Answer 12

Government program to report clinically adverse events

Question 13

Laboratory Tests
Elevated Alkaline Phosphatase

Answer 13

Children and adolescents normally have higher blood levels compared with adults because of growing bone. It is produced by the osteoblasts.

Question 14

Right to Consent and Confidentiality

No parental (or guardian) consent is necessary for the following:

Answer 14

Contraception
Treatment for STDs
Diagnosis and management of pregnancy

Question 15

Emancipated Minor Criteria

These minors may give full consent as an adult without parental involvement:

Answer 15

Legally married
Active duty in the armed forces

Question 16

Confidentiality

Confidentiality can be broken in the following situations:

Answer 16

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 (especially mental health providers)

Question 17

Puberty starts at Tanner stage II in girls _____or boys ____________. Puberty ends at stage V (adult stage).

Answer 17

(breast bud)

(testicular enlargement and scrotal rugation/color starts to become darker)

Question 18

Tanner stage III in boys is

Answer 18

elongation of the penis (testes continue to grow).

Question 19

Adolescent health history is obtained from

Answer 19

both parent and child initially; then the adolescent is interviewed alone without the parent.

Question 20

If not related to sexual activity, then need parental consent is needed;
example:

Answer 20

(dysmenorrhea, headache, upper respiratory infection [URI]).

Question 21

Delayed Puberty

Answer 21

Absence of secondary sexual characteristics by the age of 13 years for girls (such as a breast bud) or at the age of 14 years for boys.

The child remains in Tanner stage I (prepubertal).

Question 22

Primary amenorrhea:

Answer 22

No menarche by the age of 15 years in the presence of normal growth and secondary sex characteristics.

Nearly half of cases are caused by chromosomal disorders (43%) such as Turner syndrome.

Question 23

Secondary amenorrhea:

Answer 23

No menses for more than three cycles or 6 months if previously had menses. Most common cause is pregnancy.

Others are ovarian disorders, stress, anorexia, and polycystic ovary syndrome (PCOS).

Question 24

“Female athlete triad”:

Answer 24

Anorexia nervosa/restrictive eating, amenorrhea, and osteoporosis

Question 25

Anorexia Nervosa

Answer 25

-Recognize how anorexic patients present (i.e., lanugo, peripheral edema, amenorrhea, significant weight loss >10% of body weight).

-Increased 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

Clinical Findings

Marked weight loss (BMI ≤18.5), bradycardia (40–49 beats/min), vital signs unstable, hypotension
Lanugo (increased lanugo, especially in the face, back, and shoulders)
Osteoporosis or osteopenia
Swollen feet (low albumin), dizziness, abdominal bloating

Question 26

Gynecomastia

Answer 26

Excessive growth of breast tissue in males.

-Can involve one or both breasts.

-Most cases resolve spontaneously within 6 months to 2 years.

Objective Findings

Round, rubbery, and mobile mound (disklike) under the areola of both breasts (Figure 1). 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.

Treatment Plan

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).

Rule out serious etiology (e.g., testicular or adrenal tumors, brain tumor, hypogonadism).

Recheck patient in 6 months to monitor for changes.

Question 27

Pseudogynecomastia

Answer 27

Bilateral enlarged breast is due to 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.

Question 28

Adolescent Idiopathic Scoliosis

Answer 28

Lateral curvature of the spine that may be accompanied by spinal rotation.

. Rapid worsening of curvature is indicative of secondary cause (e.g., Marfan or Ehlers–Danlos syndrome, cerebral palsy, myelomeningocele).

Scoliosis treatment needed for a ≥20-degree curve; for curves <20 degrees, observe for worsening.
Screening test for scoliosis is the Adam’s forward bend test.

Classic Case

Teen complains that one hip, shoulder, breast, or scapula is higher than the other (Figure 1). No complaints of pain.

Treatment Parameters

Curves <20 degrees: Observe and monitor for changes in spinal curvature
Curves of 20 to 40 degrees: Bracing (e.g., Milwaukee brace)
Curves >40 degrees: Surgical correction with Harrington rod used on spine and other options
Management

Check Tanner stage (Tanner stages II–V).
Order spinal x-ray (posterioanterior [PA] view) to measure Cobb angle.
Refer all patients with scoliosis to a pediatric orthopedic specialist.

Question 29

Osgood–Schlatter Disease

Answer 29

The knee pain improves with rest and avoidance of aggravating activity. Reports the presence of bony mass on the anterior tibial tubercle that is slightly tender. Almost all cases resolve spontaneously within a few weeks to months. Rule out avulsion fracture (tibial tubercle) if acute onset of pain posttrauma (order lateral x-ray of knee).

Treatment Plan

Follow RICE:

Question 30

Klinefelter Syndrome

Answer 30

A condition in which males are born with an extra X chromosome (i.e., 47, XXY).

Condition occurs approximately in 1 in 1,000 live births. It is one of the causes of primary hypogonadism (deficiency in testosterone).

Testicles are small and firm with small penis. Tall stature, wider hips, reduced facial and body hair, and higher risk of osteoporosis (compared with normal males).

Treatment includes testosterone replacement and fertility treatment.

Question 31

Salter-Harris Fracture

where?

Dx?

complications?

tx?

Answer 31

where?
-growth plate fracture
-pain/decreased ROM/swelling

Dx?
-XRAY

complications?
-stunted growth

tx?
1-5 SCALE

1,2 = casting, splinting
3,4,5 = Refer