paeds and adolescent Flashcards
precocious puberty
ddx
Ix
Central HPOT Most common 80% idiopathic Central Trauma Tumors CAH or McCune albright syndrome Infection or inflammation irradiation Hydrocephalus
Peripheral Less common Thyroid Chronic primary hypothyroidism Ovary Granulosa cell 5% Thecoma Gonadotrophism Teratoma Cytoderoma Adrenal tumor McCune Albright syndrome exogenous Outflow tract Trauma Foreign bodies
Hormone panel LH FSH E P androgen panel DHEAS 17 OHP hcg FBC TFT LFTs U+Es Pelvic USS XR bone age
Directed imaging
CT or MRI brain if central cause
Adrenal or pelvic imaging if peripheral
Hx and exam for precocious puberty
Perineal hygiene Hx of putting things into vagina Ask about hair and breasts Medical conditions – CNS disease, irradiation, trauma Medications Headaches
Developmental history - height compared to peers
Development compared t peers
Abuse hx
Fhx hx – mothers menarche, mothers contraception
Visual fields Cafe au lait spots Secondary sexual characteristics Breasts Hair External trauma , virilisation
End of the bed
Observe relationship between mother and child
Height
Weight growth velocity bone age
Secondary sexual characterisitis – breasts, hair (axillary and pubic) acne
Signs of virilisation
Neurological examination - Visual fields
Abdominal masses
Vulvovaginal lesions, Foreign bodies
Ddx bleeding in a young girl
Consider:
Vulvovaginitis - inquire about perineal hygiene
Exogenous steroids - unlikely, mother uses IUCD
Foreign Body - missing toy or putting objects into vagina
Worms - nocturnal anal pruritus
Trauma - history should be obvious
Sexual Abuse - inquire discreetly if this is at all possible
Precocious puberty
Investigations:
FSH, LH - pubertal levels
Oestradiol - pubertal levels
DHEAS, 17OHP - normal range
TFT’s - normal range
HCG (gonadotropin secreting tumours) - negative
Bone Age (must be done as baseline) - advanced epiphyses not yet closed
Pelvic Ultrasound - exclude pelvic tumour - normal
MRI of CNS - exclude cerebral tumour - normal
(GnRH stimulation test clearly distinguishes CPP from PPP)
Explain and treat idiopathic precocious puberty
The investigations we have done have not found an organic abnormality to explain the pubertal changes that have occurred. The changes are caused by premature release of gonadotrophins from anterior pituitary.
If untreated your bones will fuse early and you will be short. this is why we recommend treatment.
Treatment:
GnRH agonist is the treatment of choice, causing reversible inhibition of HPO axis
Pubertal changes stabilise or regress
Growth velocity and skeletal maturation slow
Continued until normal puberty is desired
Social Support/ Counselling
Hx
Exam
Ddx
Ix for primary amenorrhea
History medical conditions / radiation chemo or toxin exposure maternal / sister menarche BMI / diet / exercise / visual changes / headache / hot flushes galactorrhoea
Exam H W BMI Signs of turners stigmata tanner stage - breast development and pubic hair external genitalia signs hyperandrogenism - hirsutism / acne / increased pigmentation / excess hair growth Ddx H GnRH deficiency Diet / anorexia / excessive exercise P Insufficiency Thyroid / prolactin O Ovarian failure - POI (Turners) PCOS Gonadal dysgenesis
A
Cushings
CAH
androgen secreting tumor
T Outflow tract abn - MRKH transverse septum imperforate hymen AIS / 5a reductase deficiency
Ix Investigations Bhcg FBC U+E LH FSH E P T Prolactin TFT DHEAS SHBG 17 OHP Karyotype Pelvic USS +/- MRI Bone age - XR Other eg brain MRI
