Lecture 7: Adolescent Medicine

Question 1

Understanding normal development

Answer 1

• Tasks of Adolescence
  
  • Transition from childhood to adulthood
  • Identity, Autonomy, Mastery of Self
• Adolescence is a very dynamic time
• Must understand what is normal to define what is abnormal
• Intervention and prevention strategies are most effective when they are developmentally based – one size does NOT fit all

Question 2

Adolescent basics (10-24 years)

Answer 2

• most teenagers are healthy
• most unhealthy lifetime habits start during adolescence
• most deaths are related to developmental/psychosocial issues
• adolescents MUST be interviewed alone to maximize
  
  • confidentiality
  • therapeutic rapport
  • disclosures
• ensuring confidentiality has caveats
  
  • suicidal intent
  • duty to warn (homicidal intent, mandated reporting, etc.)
  • disclosure of physical or sexual abuse to law enforcement
• at this point, the adolescent must be granted the right to have a confidential exam

Question 3

confidentiality

Answer 3

• If any of these things are disclosed, you are mandated by law to inform authorities: suicide, physical or sexual abuse
• You are not mandated to report on an someone over 18
• The provider has to submit the CPS case

Question 4

cognitive development

Answer 4

• 19 years
• 10 years
• ability to think abstractly
• ability to analyze situations logically
• ability to think realistically about the future, goal setting
• moral reasoning
• entertain hypothetical situations, use of metaphors
• need guidance for rational decision making

Question 5

adolescent stages: early (~10-13 years - middle school)

Answer 5

• characteristics
  
  • greatly self-conscious; need for privacy & preoccupation with body – beginnings of emancipation (separation from parents)
  • mood swings
  • EGOCENTRIC; rule and limit testing – “invicibility”
  • same sex friendships
  • profoundly concrete, no consideration of tomorrow – focus on present and near future
• risks for youth in this stage
  
  • focus on here and now
  • don’t plan, don’t abstract
  • may not see or comprehend danger
• strategies
  
  • concrete – repeat, repeat, repeat
  • time for processing – look for the light bulb
  • role play
  • provide examples of immediate cause and effect

Question 6

adolescent stages - middle (~14-17 years)

Answer 6

• characteristics
  
  • autonomy with limit-testing
  • development of identity – peer scene; concern with appeal to opposite/same sex
  • self-involved (high expectations & poor self-concept)
  • development of ideals and selection of role models
  • examination of inner experiences
  • focus of history = interaction with family, school and peers
• risks
  
  • high risk experimentation is common
  • perceived risk may be favorable
  • saving face with peers
  • prone to negative role models
  • separation from adults
• strategies
  
  • peer advocacy – positive peer pressure, take a step back
  • provide healthy, positive role modeling – mentoring
  • structure – provide options for experimentation, time to explore limits
  • opportunities for leadership and responsibility (autonomy)
  • be open, non-judgmental in communication – provide options and choices
  • don’t engage in power struggles
  • focus on building life skills (decision-making, values clarification, communication (feelings, thoughts)

Question 7

adolescent stages - late (“young adult”)

Answer 7

• Characteristics
  
  • realize vulnerabilities and limitations
  • planning for future – higher level of concern for future and one’s role in life
  • capable of useful insight, abstract thinking and independent decision-making
  • greater concern for others
  • established sexual identity
  • focus of visit = patient’s responsibility for their own health
• risks
  
  • life choices reflect exposure, options, experience, social environment
  • irreversible consequences of earlier developmental issues (e.g., chronic disease)
• strategies
  
  • validate decision making process
  • look at choices, assist with options
  • provide opportunities to explore self and skills, help with scenarios
  • work with greater sense of altruism

Question 8

HEADSS

Answer 8

• designed to open a dialogue between practitioner and adolescent
• great indicator for high risk behavior
• opportunity to reinforce and affirm positive behaviors
• HEADSS mnemonic
  
  • H: home/family life and relationships
  • E: education/employment/life goals and plans
  • A: activities/fun/friends/gang activity
  • D: diet/body image/drugs-substance use/tobacco/alcohol
  • S: sexual activity (debut, # partners, orientation,etc.)/sexual assault
  • S: suicidal (and homicidal) ideation and depression

Question 9

exercise

Answer 9

• Consider how, in a clinical situation, to target health promotion measures to the individual adolescent:
  
  • A 13 year old boy binge drinks every weekend with his friends.
  • A 16 year old girl is having unprotected sex, and is sure she cannot become pregnant because her menses are irregular.
  • An 18 year old boy rides a motorcycle without a protective helmet.

Question 10

puberty - the biologic task of adolescence

Answer 10

• The development of secondary sex characteristics
• The establishment of sexual dimorphism
• The development of reproductive capacity
• occurs in predictable, ordered sequence of events (Tanner staging)
• the trigger is internal biologic clock (pulsatile secretion of GnRH)
• change in body size and shape – timing is not the same for every person
• girls before boys, and boys longer than girls

Question 11

normal puberty facts

Answer 11

• Normal onset
  
  • Females: 8.0 - 13.0 years
  • Males: 9.0 to 14.0 years
  • Entire process can take 3-7 years, with reproductive capability achieved with 2-3 years after onset.
• Terms:
  
  • adrenarche: onset of adrenal (not testes) androgen production, resulting in pubarche
    
    • results in pubic hair development
  • gonadarche: onset of pubertal function of gonads (FSH/LH) – estrogen and testosterone start being produced
  • pubarche: onset of sexual hair development (androgen)
  • thelarche: onset of breast development (ovarian estrogen)
  • menarche: onset of menstruation
• Adrenarche precedes gonadarche by several years (2 years)

Question 12

growth spurt

Answer 12

• Period of peak height velocity (PHV, pubertal growth spurt)
  
  • Acceleration of growth rate from 5 cm/yr to possibly 15 cm+ in just few months.
  • Girls > boys, but ultimately gender disparity
  • Early puberty – “all hands and feet”
  • Girls PHV = Tanner 2-3. Boys PHV = Tanner 3-4
  • Growth stops 2-3 years later.

Question 13

tanner staging (sexual maturity rating)

Answer 13

• Classifies level of pubertal maturation and determines normality
• Divided into 5 classes based on
  
  • pubic hair/breasts in females
  • pubic hair/genitalia in males
• Linear growth extremely variable in adolescence- poor reference point
• Record at initial general PE and yearly thereafter

Question 14

tanner staging (breast)

Answer 14

• Tanner 1 (prepubertal)
  
  • No glandular tissue
  • Areola conforms to general chest line
• Tanner 2 (thelarche)
  
  • Breast bud, areola widens
• Tanner 3
  
  • Larger with more elevation, extending beyond areolar parameter
  • Areola enlarges, still in contour with breast
• Tanner 4
  
  • Larger with more elevation
  • Areola and papilla form mound projecting from breast contour
• Tanner 5
  
  • Breast adult
  • Areola and breast in same plane

Question 15

tanner staging (pubic hair/genitalia)

Answer 15

• Tanner 1 (prepubertal)
  
  • No pubic hair
  • Genitalia childlike
• Tanner 2
  
  • Light, downy pubic hair
  • Penis, testis slightly larger
  • Scrotum more textured
• Tanner 3
  
  • Pubic hair extends across pubis
  • Penis larger in length
• Tanner 4
  
  • Pubic hair more abundant and curling
  • Genitalia resemble adult
  • Scrotum darker
• Tanner 5 (adult)
  
  • Pubic hair adult quality with extension to inner border of thighs
  • Testis and scrotum adult in size

Question 16

female sexual development

Answer 16

• thelarche triggers breast buds
  
  • Sexual development begins Tanner 2, mean age 10.5 yrs (8.0-12)
  • Normal sequence: thelarche > PVH > pubarche > menarche
  • Thelarche precedes pubarche (1-1.5 years) and menarche (2-3 years) (12.6 years Caucasian; 12.1 years AA)
  • Growth spurt begins Tanner 2 and is approximately 99% complete by bone age 15 years

Question 17

male sexual development

Answer 17

• first sign of male puberty is testicular development
  
  • Sexual development begins Tanner 2 (testicular enlargement), mean age 11.5 yrs (9-13)
  • Tanner 4 usually associated with fertility, facial hair, voice change
  • Typical sequence: testicular development > pubarche > PVH
  • Growth spurt begins Tanner 2 and 99% complete at bone age 17 years.

Question 18

growth and height

Answer 18

• Arrest of previously normal pubertal growth rate in adolescent is abnormal and warrants thorough evaluation for endocrine, metabolic, and systemic disorders
• Height largely determined genetically, “target height” =
  
  • Average of parents’ heights + 6.5 cm for boys
  • Average of parents’ heights – 6.5 cm for girls

Question 19

normal variants of puberty

Answer 19

• Breast asymmetry
• Physiologic leukorrhea
  
  • Typically begins 6 to 12 months before menarche
  • Due to ovarian estrogen stimulation of uterus and vagina
  • Discharge clear, no odor or irritation
• Irregular menses – physiologic adolescent anovulation
  
  • 50% anovulatory cycles (immature axis) during first 2 years
  • Menstrual regularity in 2/3 girls within 1 year menarche
    
    • By 2 years, 10% girls irregular
    • By 5 years, 75% cycles are ovulatory
• Gynecomastia
  
  • Breast enlargement in boys
  • Usually benign, self-limited (< 1-2 years)
  • 50-60% of adolescent boys
  • Often idiopathic, but consider other causes of severe or persistent
  • Tanner 3, mobile, tender, firm mass beneath areola
  • Reassurance, reduction mammoplasty

Question 20

issues arising with puberty

Answer 20

• Anemia
• Acne
  
  • Treatment based upon severity (comedonal, inflammatory, nodular, cystic)
  • moderate or severe acne in early puberty, usually with other signs of androgen excess, consider endocrinologic disorder
• Psychological changes
  
  • Depression: girls > boys
  • lack of synchrony between the timing of pubertal development and chronologic age exists
    
    • early female
    • late male
• Musculoskeletal injuries
  
  • greatest risk to epiphyseal growth plates occurs during PHV
• Abnormal uterine bleeding

Question 21

delayed puberty

Answer 21

• Who should be evaluated?
  
  • no sign of pubertal development by age 13 in girls (no thelarche)
  • no sign of pubertal development by age 14 in boys
  • accompanied by slowing of linear growth velocity – short stature may be first complaint
• Is it normal variant or pathological?
  
  • constitutional delay (“late bloomers”) – normal variant (>90% cases)
    
    • THE MOST COMMON REASON FOR SHORT STATURE AND DELAYED PUBERTY IN KIDS
      
      • Ask kid what age parents started puberty
      • If bone age is inconsistent with the age, then it’s a concordance of delay
    • family history; once puberty begins, catch up growth to target height occurs
    • delayed bone age (between 1.5 – 4 years)
  • central
    
    • hypogonadotropic hypogonadism
      
      • adrenarche occurs to some degree, but gonadarche does not
      • may accompany chronic illnesses, anorexia nervosa (malnourishment), athletic amenorrhea, hypothyroidism
    • gonadtropin (GnRH) deficiency
      
      • larger syndrome or chronic illness (acquired)
      • Consider congenital hypopituitarism
    • CNS tumor (e.g., craniopharyngioma)
  • gonadal
    
    • hypergonadotropic hypogonadism (gonadal failure)
      
      • Turner (XO) syndrome – suspect in any short female
      • Kleinfelter syndrome (47, XXY)
  • chronic disease (IBD, JRA, CF, SCD, SLE)

Question 22

sports pre-participation exam

Answer 22

• Goals:
  
  • Identify medical and musculoskeletal conditions that could make sports participation unsafe (with consideration of sport)
  • Screen for underlying illness through medical and family hx, ROS and PE
  • Opportunity for general health assessment and preventive care
  • Entry into medical care – promotes provider-patient relationship

Question 23

sports exam

Answer 23

• NEED TO EXCLUDE CARDIAC PATHOLOGY
  
  • 50 of 51 states (including the District of Columbia) require some form of physical evaluation before participation in sports at the high school level.
  • History most important aspect, with 3 key elements:
    
    • Cardiac system
    • Neurologic system
    • Musculoskeletal system
  • Consider sport for which athlete is being screened
    
    • Sports are graded, based on level of contact (high, moderate, low)
    • Injury patterns generally associated with contact grade

Question 24

classification of sports according to contact/collision

Answer 24

• Consider:
  
  • Macrotraumatic/acute traumatic injury
    
    • one-time, kinetic energy force applied to body common in high contact sports (soccer, football, lacrosse)
    • Focus on h/o concussion, fracture, ligamentous injury
  • Microtraumatic or overuse injury
    
    • seen frequently in repetitive use sports (running, swimming)
    • More common in moderate and low contact sport categories
    • Example: Tennis elbow, shin splints
  • AAP opposes participation in boxing for children, adolescents and young adults
  • AAP recommends limiting bodybuilding and power lifting until adolescent achieves Tanner 5

Question 25

review of cardiac system history

Answer 25

• Cardiac system
  
  • Sudden cardiac death comprise majority of sport-related fatalities
    
    • Most common causes: hypertrophic cardiomyopathy (>50%), Marfan syndrome, total anomalous pulmonary venous system, long QT syndrome
    • Currently, ECG not universally recommended
  • Most important questions to include (**) in Hx or ROS:
    
    • Syncope or near syncope during or after exercise?
    • Discomfort, pain, tightness or pressure in chest during exercise?
    • Palpitations during exercise?
    • Lightheadededness, shortness of breath, or fatigue more than expected during exercise?
    • H/O heart problems or past testing for heart?
    • Family member died of heart problems or unexplained death before 50 yo, or current family member with heart disease?
    • Family member with unexplained fainting or drowning?
  • H/O concussions, injuries, fractures?​
  • Syncope
    
    • During exercise, concerning for cardiac disorder –
      
      • anatomical (HCM)
      • conduction (prolonged QT, Wolfe-Parkinson-White syndrome)
    • If occurs while standing or sitting with no other pertinent hx, NOT contraindication
    • If present during exercise, CONTRAINDICATION with immediate cardiology referral

Question 26

review of medical history: asthma and recent mononucleosis

Answer 26

• Asthma
  
  • 85% of asthmatics = exercise-induced
    
    • Incidence 10-35%, & likely underdiagnosed
    • Entertain in anyone with h/o wheezing, SOB during activity
    • Consider spirometry and PFT to assess degree of obstruction
• Recent Mononucleosis
  
  • Mono-induced splenomegaly can result in splenic rupture (high or moderate contact sports)
  • If h/o mono within 1 month, pt. at risk since spleen size peaks within 3-4 weeks
  • If PE suspicious for palpable spleen, order ultrasound or CT before clearance.

Question 27

review of medical history: unilateral organ, seizure disorder, current meds, menstrual hx, ergogenic aids

Answer 27

• Unilateral organ (kidney, testicle)
  
  • Single kidney – contraindication to high-contact sports
    
    • Moderate contact sports – require protective “flak” jacket
  • Single testicle – require mandatory protective cup use for all sports
• Seizure disorder
  
  • Not direct contraindication if well controlled (no seizure in last year)
  • If ongoing seizure activity, warrant special attention, especially if aquatic sports
  • h/o seizure within past 6 months, concern
• Current Medications – important to document
  
  • linked to arrhythmias:
    
    • tricyclic antidepressants (imipramine), macrolide antibiotics (erythromycin), OTC decongestants (pseudoephrine), illicit drugs (cocaine, amphetamines)
• Menstrual history
  
  • Screen for amenorrhea – female athlete triad
    
    • Anorexia, amenorrhea, osteoporosis
    • Consider bone density studies via DEXA
• Ergogenic aids
  
  • Steroid use
  • Nutritional supplement – incidence increasing
  • “Have you ever taken a substance to enhance your athletic performance?”

Question 28

physical exam

Answer 28

• Focus on sports readiness
  
  • Height and weight:
    
    • Indicate growth and development - general fitness (eg, obesity) and pathology (eg, eating disorders).
    • Risks for competing at certain levels. A common minimum weight for varsity football participation is 120 lb
  • Blood pressure (BP):
    
    • Certain sports may cause significant BP elevations, and this may be a reason to limit an athlete’s participation.
    • Evaluate more than once, consider normal BPs for the age
  • Consider secondary hypertension related to steroid use
  • Grade III hypertension requires removal from athletics until controlled. Grade IV is contraindication.

Question 29

physical exam visual acuity, skin

Answer 29

• Visual acuity
  
  • poor vision can affect performance and increase likelihood of injury.
  • Visual acuity (20/40 for clearance)
• Skin
  
  • Wrestling, disqualify athletes who have infectious dermatoses:

Question 30

physical exam: cardiac, abdomen, genitalia (mandatory for males)

Answer 30

• Cardiac
  
  • murmurs or irregular rhythms?
  • HOCM: systolic murmur along the left sternal border, accentuated by Valsalva maneuvers and standing; the murmur decreases with handgrip and squat maneuvers.
• Abdomen
  
  • Organomegaly (splenomegaly)
• Genitalia (mandatory for males)
  
  • Tanner staging classify athletes by maturity; thus, developmental delays can be detected.
  • Single testicle & hernias.
  • Tanner staging correlates better with skeletal maturity (vs. physical size)
    
    • Growth plate fractures – muscular force exerted by testosterone-rich muscles across cartilaginous physes predisposes

Question 31

physical exam: musculoskeletal

Answer 31

• “two minute” orthopedic evaluation.
  
  • Note the general body habitus & assess for symmetry.
  • Assess cervical ROM.
  • Assess shoulder function:
    
    • shoulder shrugs (trapezius)
    • abduction to 90° (deltoids), both against resistance
    • internal and external rotation (glenohumeral joint).
  • Forearms supination and pronation w/elbows flexed to 90°.
  • Hands open and close his or her fists and spread the fingers.
  • Lumbar spine extension (spondylolysis and spondylolisthesis).
  • Scoliosis check, spine ROM and hamstring flexibility.
  • Toe walk/heel walk (leg musculature symmetry, calf strength and balance).
  • Duck walk (hips, knees, and ankles, strength and balance).
  • Knee extension and patellar tracking.
• Musculoskeletal: source of most pathology
  
  • Cervical spine injuries/pathology – cervical radiographs
    
    • Down’s Syndrome – atlantoaxial instability
  • Spine problems –
    
    • Scheurmann khyphosis/scoliosis
      
      • Scoliosis: females>males
      • Kyphosis: males>females
    • spondylolysis/sponndylolithesis – pain with extension
    • Discogenic back pain – low back pain
    • Pain with flexion=discogenic; pain with extension=posterior element overuse; rotational pain=paraspinous muscle pain
  • Shoulder (problems in overhead sports) –
    
    • rotator cuff overuse
    • shoulder instability
  • Knee
    
    • Focus on h/o knee pain
    • Persistent pain with flexion, swelling – 4-view knee series to r/o osteochondritis dessicans
    • Screen for ligamentous instability
  • Ankle
    
    • Chronic problems related to repetitive sprains and subsequent instability

Question 32

conditions that contraindicate sports participation

Answer 32

• Active myocarditis or pericarditis
• Hypertrophic cardiomyopathy
• Severe hypertension until controlled by therapy (static resistance activities, such as weight lifting, are particularly contraindicated)
• Long QT interval syndrome
• History of recent concussion and symptoms of postconcussion syndrome (no contact or collision sports)
• Poorly controlled convulsive disorder (no archery, riflery, swimming, weight lifting or power lifting, strength training or sports involving heights)
• Recurrent episodes of burning upper-extremity pain or weakness, or episodes of transient quadriplegia until stability of cervical spine can be assured (no contact or collision sports)
• Sickle cell disease (no high-exertion, contact or collision sports)
• Eating disorder where athlete is not compliant with therapy and follow-up, or where there is evidence of diminished performance or potential injury because of eating disorder
• Acute enlargement of spleen or liver