Case 5,6: 16yo WCC Flashcards
important components of teenage WCC
HEEADSSS
confidentiality issues
Tanner stages
Acne
Home environment, Education and employment Eating Activities - peer-related Drugs Sexuality Suicide/depression, Safety from injury and violence
diffdx for (young female):
fatigue, less active, poor academic performance, pale
- anemia: iron deficiency == bone marrow otherwise normal
- anemia: bleeding disorder == more rapid loss of HgB (more SEVERE FATIGUE) ==> (esp. with hx of heavy menstrual periods) menorrhagia
- hypothyroidism ==> menorrhagia, shorter menstrual cycles + constipation, weight gain, appetite
- depression
- adjustment disorder
- eating disorder
- drug abuse
considerations of bleeding disorders
- heavy, prolonged menstrual periods
- frequent nose bleeds (+/- clots)
- easy bruising
- piercings that don’t heal for a while
- problems with prior surgeries (tonsillectomy, wisdom teeth)
- Fhx of trouble with clotting
von Willebrand disease
LOW
- Hgb
- Plts
- MCV
PROLONGED
- reticulocyte count
- bleeding time
- PTT (+/-
- Factor 8 activity
- vWF antigen
- vWF activity
NORMAL
- PT
Which of the following are more commonly found in children / adolescents v. adults
B. early morning waking
what are the best screening tools for depression for children (and for what age groups)
- Children’s Depression Inventory (CDI) = 7-17yo
- Beck Depression Inventory (BDI) = adolescents
- Center for Epidemiologic Studies Depression (CES-D)
“Have you ever felt that life is not worth living?”
“Have you ever felt like you wanted to kill yourself?”
Screening questions for eating disorders
- Have you tried to lose weight?
- Are you unhappy about your weight or appearance?
- Do you worry about eating?
- Do you feel obsessed with food?
- Do you know about anorexia or bulimia?
- Has there been anybody with anorexia or bulimia in your family?
- Do you know of anybody with anorexia or bulimia?
- Have you been exercising a lot more than usual?
- Have you been taking laxatives that haven’t been given by a doctor?
FHx
- similar eating d/o
- other psychiatric illness (suicidal attempts, depression)
Key parts of physical exam for a teenager
Skin: Clubbing; atypical nevi, tattoos, piercings, and signs of abuse or self-inflicted injury
Eyes: Jaundice (sclera)
Pallor (often difficult to tell until Hb < 6 g/L)
General well being
Height/weight/BMI plotted on percentile charts, general nutrition and muscle bulk
signs of hypothyroidism in an adolescent
What is unique in an adolescent (v. adult)
- Cold skin
- Slowness
- Fatigue
- Preferring hot weather to cold
- Doing poorly at school
- Coarse hair
signs & sxs of infectious mononucleosis
- extreme fatigue
- pharyngitis
- lymphadenopathy
in adolescent women, what are menses like?
do they produce clots?
light & irregular (esp. in first 2y)
KEY features
- cramping
- discomfort
- NO CLOTS
diffdx of depressive sxs in adolescents
- mood swings
- adjustment reactions (moving; breakup) == usually short
when evaluating a teen for depression, what is the ONE question you always have to ask?
thoughts / hope / plans for suicide +/- hx of self injury,
which is more difficult to diagnose : anorexia or bulimia
Both are difficult in early stages ==> severe emaciation, over-excercising, laxative taking
bulimia –> due to lack of weight loss in early stages
==> dental decay (stomach acid); finger trauma
signs associated with anorexia (weight loss, failure to gain weight)
what happens in SEVERE cases?
- amenorrhea
- bradycardia ==> decreased CO +/- postural hypotension
tx == hospitalization (+ therapists) for prevention of worsening condition & nutrition
SEVERE
- electrolyte abnormalities (hypoalbumin, hypoglycemia, hyponatremia, hypoCa, hypoMg)
+/- neurologic changes, increased reflex tone, compromised cardiac fx
define: constitutional short stature
individual who is a “late-bloomer” in
puberty, but will attain a normal adult height-just later than his or her peers
Tanner Stages: female
8-13yo ==> puberty
1) breast buds = 10-11yo
2) pubic hair = 10-11yo
3) growth spurt = 12yo
4) periods = 12-13yo
adult height = 15yo
Tanner Stages: male
10-15yo ==> puberty
1) testicles = 12yo
2) pubic hair = 12yo
3) growth of penis, scrotum = 13-14yo
4) first ejaculation = 13-14yo
5) growth spurt = 14yo
adult height = 17yo
von Willebrand Disease genetics
AD with variable penetrance
Type 1 = most common (70%) - not life treatening
von Willebrand Disease genetics
sxs
- ecchymoses (easy bruising)
- epistaxis
- menorrhagia
- bleeding post-dental, tonsil extractions
- gingival bleeds
- bruising in non-exposed areas
von Willebrand Disease genetics
tx
- intranasal / IV demopressin
- human plasma-derived / virally inactivated vWF concentrate
- symptomatic treatment for menorrhagia = OCPs, levonorgestrel IUD.
von Willebrand Disease genetics
tx
1) intranasal / IV demopressin
2) human plasma-derived / virally inactivated vWF concentrate
3) (TRAUMA, SURGERY) = factor 8 concentrate
- symptomatic treatment for menorrhagia = OCPs, levonorgestrel IUD.
important components of preparticipation evaluation (prior to sports) in teen
- CV screening (esp. for HOCM) + FHx
- hx of LOC or concussion
- hx significant MSK injuries
- general health + health-related issues + fitness level for specific sports
vasovagal reflex
vasovagal syncope ==> bradycardia and/or peripharl vasodilation
prodromal sxs = dizziness, lightheadedness, sweating, nausea, weakness, visual changes
+/- syncope
osgood schlatter disease
- cause
- tx
- prognosis
- cause: irritation of growth plate at tibial tuberosity
- tx: ice, NSAIDs
- prognosis: self-limited growing pain (with finishing growth spurt, once bones stop growing)
diffdx chest pain in teenagers
- precordial catch syndrome ==> sudden, sporadic (sharp) along LSB, worsened with deep inspiration. resolve spontaneously, worsened with forced deep inspiration. NOT with exercise
- costochondritis ==> inflammation along sternal border @ articulations of ribs to sternum; last for h-d
- GI == retrosternal, burning, non-radiating, associated with meals (esophageal/gastric irritation ==> OCPs, EtOH, tobacco, iintoxicants, stimulants, cocaine)
- asthma-/exercise-induced bronchospasm ==> + cough, wheeze, respiratory distress
Key evaluation points in w/up of chest pain in children
- fever ==> infectious (pericarditis, pneumonia)
- body habitus: genetic d/o assoc. w/ cardiac problems (Marfan’s)
- CV: thrill, hyperdynamic precordium, murmurs
- chest wall for injury ==> if reproducible pain with palpation ==> MSK
signs and sxs of cardiac causes of chest pain
- onset:
- quality:
- duration:
- associated sxs:
- exam findings:
onset = pain triggered by exertion, stress
- quality: pressure, crushing sensation
- duration: 10-15min
- associated sxs: syncope, palpitations
- exam findings: murmur, thrill, hyperdynamic precordium
what vaccines should a 16yo who has had all other childhood shots get?
- HPV ==> 9-11yo (3 over 6mo)
- meningococcal (esp. since going to college soon): MCV4 ==> 11yo (booster at 16y); MenB ==> 16yo (1x)
- Tdap ==> 11-12yo (1x)
- annual flu
Which of the following would NOT be in keeping with hypothyroidism? (Select the ONE best answer.)
A Cold skin B Sweaty, with palpitations C Rash on legs D Preferring hot weather to cold E Feet edema F Coarse hair
B
sweaty (heat intolerance) ==> hyperthyroidism
hypothyroidism = cold skin, depression, rash on legs, prefer hot weather, feet edema, coarse hair
f the depression symptoms below, which ONE is more common in adults than in adolescents?
A Feels down and doesn’t want to do his or her normal activities.
B Wakes early in the morning; has difficulty falling asleep at night.
C Feels sad and often cries over small things.
D Doesn’t want to participate in friends’ activities.
E Thinks about suicide.
F Feels grouchy and flat all the time.
B
which of the following would be the expected progression of clinical, laboratory, and ECG findings as her anorexia became more and more severe?
A Bradycardia, electrolyte imbalances, arrhythmias, circulatory collapse, death
B Proteinuria, hypoglycemia, seizures, circulatory collapse, death
C Hyponatremia, cerebral edema, seizures, circulatory collapse, death
D Hypotension, fracture, fat embolus, myocardial infarction, death
E Proteinuria, pericardial effusion, pericardial tamponade, circulatory collapse, death
A
1) bradycardia
2) electrolyte imbalances
3) malnutrition issues = hypoalb, hypoGlucose, hypoNa, hypoCa, hypoMg
4) neurologic changes, increased reflex tone, and compromised cardiac function.
Which of the following conditions could cause a drop-off in an adolescent’s performance in school?
Multiple Choice Answer: A Hypothyroidism B Death of a close relative C Drug abuse D Depression
all of the above
A 15-year-old female comes to the clinic with a chief complaint of feeling tired for one month. She has also been complaining of frequent nosebleeds while at school and bruising easily. When further history is elicited, you find out that menarche was at the age of 9 and her periods have always been heavy and irregular. Her mother and grandmother also have histories of heavy periods and easy bruising. You suspect a bleeding disorder and send off some labs including a CBC, INR, PT, PTT, and a von Willebrand panel to confirm your diagnosis. Your suspicion was correct for the most common type of bleeding disorder. How is this bleeding disorder most commonly inherited?
A Autosomal dominant inheritance
B Autosomal recessive inheritance
C X-linked recessive inheritance
D Mitochondrial inheritance
most common = vwf
A. Autosomal dominant (AD) inheritance is the correct choice. In AD disorders males and females are equally affected within each generation. These include conditions such as von Willebrand’s disease, Marfan syndrome, neurofibromatosis, and Huntington’s disease.
90% == AD
1% == AR
A 14-year-old girl presents to your office wondering why she has not had her period yet. Her mother states that she and the patient’s grandmother reached menarche at 13 years of age. The patient is concerned she is behind her friends in terms of development. She is doing well in school and has not had developmental problems in the past. On physical examination, her breasts are elevated without a secondary mound, and curly, coarse pubic hair is present on the labia majora in a triangular shape but does not reach the mons pubis. What Tanner stage would you assign this patient?
A Tanner Stage I B Tanner Stage II C Tanner Stage III D Tanner Stage IV E Tanner Stage V
C
Female: Tanner stage I
= 10yo
Breasts = no glandular tissue and is prepubertal.
Pubis = no pubic hair at all
Female: Tanner stage II
> 10yo
Breasts = breast buds form and the areola begins to widen
Pubis =small amount of long, downy hair with slight pigmentation appears on the labia majora
Female: Tanner stage III
13-14yo
Breasts = elevated but do not have the secondary mound
pubis = extends more laterally; does not extend onto the mons pubis
Female: Tanner stage IV
15-16yo
Breasts = increased; secondary mound of areola & papilla projecting from contour of rest of breast
pubis = extends across the mons pubis, spares the medial thighs
Female: Tanner stage V
16-18yo
breasts = adult size and the areola returns to the contour of the surrounding breast while the central papilla remains projecting
pubis = extends to the medial surface of the thighs.
A 16-year-old female presents to clinic complaining of worsening fatigue. Family history is significant for hypothyroidism and heavy periods in the grandmother. Her exam reveals mild tachycardia and oozing around a recent piercing, but is otherwise normal. Labs reveal Hgb 8.5 g/dL, MCV 58, PT 12.5, PTT 44, and low von Willebrand factor activity. Which of the following is the most appropriate treatment for her underlying disorder?
A Blood transfusion and iron supplementation B Desmopressin C Factor VIII concentrate D Cryoprecipitate E Vitamin K
B
low Hgb, low HCV ==> bleeding
prolonged PTT
low vwF
==> von willebrand
disease
\only use factor 8 concentrate for trauma / major surgery
A 10-year-old female comes to the clinic for a well child exam. Her mom asks about puberty and wants to know in what order she should expect to see normal developmental changes in her daughter. Which of the following sequences is correct?
A breast bud -> pubic hair -> menarche -> growth spurt
B pubic hair -> breast bud -> growth spurt -> menarche
C pubic hair -> menarche -> breast bud -> growth spurt
D breast bud -> pubic hair -> growth spurt -> menarche
E pubic hair -> breast bud -> menarche -> growth spurt
D
tits come first
first growth spurt comes before menarche
1) breast buds = 10-11yo
2) pubic hair = 10-11yo
3) growth spurt = 12yo
4) periods = 12-13yo
Frank is 16-year-old male brought in by his mother who complains that her son “looks much younger than his age.” She states that until about four years ago, she did not notice much difference between Frank and his friends. However, in the past two years, Frank has become the shortest person in his class. Frank’s mother is concerned that he has a “hormone problem” and wants to know how she can tell if he has begun puberty. What is usually the first sign of puberty in a male?
A Growth of the penis B Appearance of pubic hair C Testicular enlargement D Growth spurt E First ejaculations
c
t’s go first
1) testicles = 12yo
2) pubic hair = 12yo
3) growth of penis, scrotum = 13-14yo
4) first ejaculation = 13-14yo
5) growth spurt = 14yo
How to talk to teens about performance-enhancing drugs
TEENS
1) undesired physical changes and side effects (bad breath, yellow teeth and cost)
2) drug testing for sports
3) examples on consequences via athletes
PRE-TEENS ==> “just say no”
ADULTS ==> long term-consequences (like CV risk, cancer)
Male: Tanner stage I
Phallus: small
Testicle: 1.5mL
Scrotum: pale
Pubic hair: none
Male: Tanner stage II
Phallus: small
Testicle: 1.6-6mL
Scrotum: reddened, thinner, larger
Pubic hair: fine hair, along base of scrotum and phallus
Male: Tanner stage III
Phallus: longer
Testicle: 6-12mL
Scrotum: larger
Pubic hair: moderate, curly, pigmented, coarser hair extending laterally
Male: Tanner stage IV
Phallus: longer, thicker
Testicle: 12-20mL
Scrotum: larger, darker
Pubic hair: coarse, curly adult hair, sparing medial surface of thighs
Male: Tanner stage V
Phallus: adult size
Testicle: 20mL
Scrotum: adult size
Pubic hair: adult hair, to medial surface of thighs
what is the difference between DTaP and Tdap?
DTaP
- for =6yo
- 3-5x more diptheria toxoid
Tdap
- for >7yo
- booster doses of diphtheria, tetanus toxoid, and acellular pertussis
What is the acronym used for asking teens about their drug use?
CRAFFT
3 initial questions
1) Drink any alcohol (more than a few sips)?
2) Smoke any marijuana or hashish?
3) Use anything else to get high?
if no to all ==> ask only “c”
if yes to any ==> ask all CRAFFT
C Have you ever ridden in a CAR driven by someone (including yourself) who was “high”
or had been using alcohol or drugs?
R Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
A Do you ever use alcohol/drugs while you are by yourself, ALONE?
F Do you ever FORGET things you did while using alcohol or drugs?
F Do your family or FRIENDS ever tell you that you should cut down on your drinking or
drug use?
T Have you gotten into TROUBLE while you were using alcohol or drugs?
Specific unique items of teenage physical exam
CV
1) BP
2) brachial & femoral pulses (? coarctation)
3) cardiac auscultation supine & standing ==> further evaluation of “physiologic” murmur if (a) > grade III/IV; (b) any diastolic; (c) any murmur that increases with standing or valsalva
GU (males only)
- inguinal hernia (esp. sprinting, weight lifting)
- undescended testicle ==> better protective cup for contact sports
- demonstrate correct testicular self-exam monthly
- Tanner staging for developmental purposes ONLY
MSK (ortho) - symmetry in:
- strength
- muscle bulk
- ROM
Are all murmurs in adolescents abnormal?
NO
can have physiologic systolic murmur
but likely Pathological if:
(a) > grade III/IV
(b) any diastolic
(c) any murmur that increases with standing or valsalva
what is the one contraindication for contact sports for having one of a pair of organs?
One kidney
but okay if have only one testicle - e.g. d/t cryptorchidism
evaluation for syncope
syncope ==> abrupt LOC and postural tone
1) physical exam + VS (orthostatic BP - supine & upright); detailed cardiac & neuro exams
2) EKG ==> arrhythmias (WPW, long QT, HOCM)
if negative ==> likely neurocardiogenic (vasovasal) cuase
what is the typical first presenting sx of HOCM?
syncope
==> need EKG, which will be abnormal in 90% of pts with HOCM
diffdx of syncope in a teenager
1) vasovagal reflex == most common
2) HOCM
3) pheochromocytoma
4) heat stroke == + very high body temp
5) hypoglycemia == most common in T1DM, + confusion, AMS
6) dehydration == would resolve with hydration
red flags in syncope in a teen that point toward cardiac cause
- Fhx of seizures, sudden death, MI in family <30yo.
- all syncope assoc. with exercise / exertion
- prolonged LOC > 5min + chest pain, palpitations (+ abn cardiac exam, hx of cardiac dz
syncope v. seizure
seizure
- facial cyanosis
- aura
- frothing at the mouth
- tongue biting
- slow recovery
- postictal drowsiness
- prolonged mental status change / confusion
- syncope in supine position
- convulsion prior to LOC
- warm/flushed/cyanotic skin color
SYNCOPE
- pale, diaphoresis
- murmur ==> cardiac cause
does creatine supplementation help athletes perform better
Not enough benefit / safety profile in teens ==> drs don’t recommend it (esp. in those with existing renal dz or risk of renal failure)
Natural sources = meat, fish
theoretically helps brief (<30sec), high intensity exercise
S/E = weight gain (water retention, cramps, heat intolerance, muscle/tendon swelling, predisposed to sprains, increased BUN/Cr/CPK
What is the most common cause of chest pain in an adolescent?
A Asthma B Gastroesophageal reflux disease (GERD) C Musculoskeletal D Myocardial ischemia E Pericarditis
C
1) MSK most common cause of chest pain in kids
2) asthma (+wheeze, SOB)
3) GERD (+acid)
S/E of anabolic steroids with long-term use
- Immediate: acne, smaller testicles
- Labile mood, reckless behavior ==> dopamine, seretonin, opioid
- withdrawal sxs
does NOT give the “high” (b/c not rapid release)
Which of the following immunizations are routinely administered at the 11-year-old well child visit? (Select all that apply.)
A HPV Human Papilloma Virus
B Meningococcal B
C Meningococcal ACYW Conjugate vaccine
D DTaP (tetanus/diphtheria/acellular pertussis)
E Tdap (tetanus/diphtheria/acellular pertussis)
A, C, E
HPV (at 11-12)
Menin Conjugate (at 11-12, booster at 16yo)
Tdap (at 11yo)
MenB = at age 16 DTap = at <6yo
John is a 17-year-old presenting today for a pre-participation physical exam. During the interview, he reports a low-grade fever, malaise, and headache for one week. In the past few days, his fever has gotten worse and he complains of a sore throat. He denies cough or chest pain. On physical examination, he is found to have a temperature of 101.3° F, and cervical lymphadenopathy and oropharyngeal erythema with exudate are noted. His participation would be most likely affected by which of the following tests?
A Chest x-ray B CT head/neck C EBV serologies D Throat culture E No further workup
C. suggestive of infectious mononucleosis. These include complaints of low-grade fever and malaise and findings of cervical lymphadenopathy and pharyngeal exudate. If testing is positive, the patient should be restricted from strenuous activity or contact sports during his illness due to the risk of splenic rupture.
Not throat culture –> b/c this is more likely mono (with fatigue & lymphadenopathy)
- if EBV serologies are negative ==> can do antigen test & culture for strep pharyngitis.
A 17-year-old boy presents for a sports pre-participation physical. He reports that he occasionally gets short of breath and feels light-headed with exercise, and sometimes he experiences chest pain as well. He lost consciousness once last season during a playoff basketball game, but attributed it to feeling sick at the time. His grandfather died suddenly at age 35 of unknown etiology. Which of the following is the most likely diagnosis?
A Hypoglycemia B Congenital heart block C Postural hypotension D Prolonged QT syndrome E Ventricular septal defect
D. Prolonged QT syndrome can cause syncopal episodes in late childhood or adolescence. QT intervals are elongated on ECG and lead to arrhythmias, like ventricular fibrillation. This condition is often associated with other abnormalities, including severe congenital sensorineural deafness.
would be HOCM if it was on the list
Postural hypotension (volume depletion, skipping meals) == very common cause of dizziness / visual changes in pedatrics
Hypoglycemia = very uncommon in healthy children; usually no chest pain
A 16-year-old male presents to your office requesting clearance to play football. You begin by taking his medical history. He says that he feels very well, but admits that he recently experienced one episode of syncope that occurred when he trained really hard for football tryouts with his friends. He denies any shortness of breath, or chest pain currently. Family history is significant for an uncle who died of heat stroke at the age of 30 while playing basketball. Physical examination reveals no abnormalities. What is the next best step in management?
A ECG now, and if normal, reassurance B Medically clear him to play C Stress test D ECG and referral to cardiology E Observe and follow up in 6 months
D. syncope with exertion == RED FLAG ==> referral to cardiology
The combination of syncope with exertion and a family history of a young death is concerning for something like hypertrophic cardiomyopathy. Don’t be fooled about heat stroke. That is a positive family history for sudden death in a young person. This patient must be evaluated by cardiology, even if you don’t hear a cardiac murmur!
A 16-year-old previously healthy male comes to the Pediatrics Urgent Care Clinic having “almost fainted” at soccer practice. He says that he had not eaten much earlier in the day and it was very hot and muggy outside. He felt light-headed and sick to his stomach. He denies losing consciousness and did not fall to the ground. He denies any chest pain. When you examine him, his eyes are sunken and he is tachycardic. What would be your next step in his management?
A Electrocardiogram (ECG) B Measure his blood glucose C Echocardiogram D Give fluids and recheck his vital signs E Stress test
D. The patient is likely dehydrated given the dizziness without loss of consciousness in the setting of poor PO intake, hot weather and exercise. As the symptoms occurred while he was upright, the likely mechanism is vasovagal. His sunken eyes and tachycardia are signs of moderate to severe dehydration. Since this is a clinical diagnosis, fluids should be given with subsequent rechecking of heart rate and blood pressure to confirm the diagnosis.
no syncopal event, no chest pain
Claire is a 16-year-old female who presents for birth control management. Her review of symptoms is unremarkable except for chest pain. When you ask her more questions, she reveals the pains are intermittent, on and off for the past couple months. It is not associated with exertion, sharp, and well localized at the left sternal border. It is very brief, lasting only a few seconds, during which she says she sometimes notices it gets worse when she breathes in. She denies recent URI or viral illness. The family history is negative for early cardiac disease. Her vital signs and physical exam are normal. Which is the next best step in management?
A ECG B Reassurance C Referral to a cardiologist D Fast ultrasound of pericardial window E Chest x-ray
B
==> precordial catch syndrome = most common cause of chest pain in an adolescent
ECG would be next if you suspected a cardiac abnormality. This would be more likely if the patient described something more like angina, a crushing chest pain or pressure, for longer periods of time rather than a few seconds, and aggravated by exercise.
most common cause of chest pain in an adolescent
precordial catch syndrome
